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COPYKIGHT DEPOSIT 



Psychopathology 
of Hysteria 

CHARLES D. FOX, M. D. 




RICHARD G. BADGER 

THE GORHAM PRESS 
BOSTON 



COPYRIGHT 1913 BY RICHARD G. BADGER 



All Rights Reserved _; 

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THE GORHAM PRESS, BOSTON, U. S. A. 



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PREFACE 

Than hysteria, probably there is not any dis- 
ease which is more interesting, which has been 
more misunderstood, which is capable of caus- 
ing a greater diversity of manifestations, and 
about which more has been written. Its absorb- 
ing interest is due mainly to the peculiar char- 
acter and unlimited possibilities of its expres- 
sion. Surely, a disease is worthy of the con- 
sideration which has been bestowed upon 
hysteria when it is capable of causing such 
diverse symptoms as paralysis, convulsions, 
blindness, multiple personality, and which can 
occur in epidemics that, in the past, have caused 
greater disturbance to whole nations than a 
war would have occasioned. Its history and 
literature, which would fill a spacious library, 
show that from the days of the Grecian oracles, 
or of the sibyls of even more distant ages, to 
the present trance mediums, the unfortunate 
victims of the disease have been subjected alter- 
nately to persecution as witches and demons, or 
to devotion as the inspired source of wisdom 
and of supernatural knowledge. 

It is only recently, and through psychologic 
means, that hysteria is beginning to be under- 
stood. The credit for elucidation of problems 
of the disease is due principally to the French. 
In fact, the psychology characteristic of their 



4 Psychopathology of Hysteria 

nation truly may be said to have been based 
upon studies of the abnormal psychology of 
hysteria. The present era of enlightenment con- 
cerning the disease may be considered to have 
been initiated by Bernheim. It is his interpre- 
tation — which to a great extent has stood the 
test of time — of the phenomena of hypnotism 
that enabled this earnest investigator to grasp 
the mysteries of hysteria in a manner which 
never before had been possible. In spite of the 
greatest opposition and acrimonious contro- 
versy, his views of the causation and nature of 
many of the symptoms of hysteria are obtaining 
at last the recognition and acceptance which 
they deserve. Babinski, for instance, the most 
ardent of the revisionists, eagerly contends 
now, as Bernheim insisted many years ago, that 
suggestion is of the utmost importance in the 
genesis of symptoms of the disease. It is to 
Janet that credit is due for the theory that dis- 
sociation of the personality is the underlying 
mechanism of hysteria, and also for innum- 
erable and valuable experimental researches 
concerning the psychic nature of the dis- 
turbances of sensory perception. Of great im- 
portance, too, was his exposition of the somnam- 
bulistic qualities of many of the manifestations. 
In this country, the most fruitful investiga- 
tions have related to dissociation of the person- 
ality ; a subject which has received considerable 
attention. Probably the most extensive and the 



Preface 5 

most valuable contributions on the clinical 
study of this condition have been made by Mor- 
ton Prince and by Boris Sidis. 

Finally, the studies of Sigmund Freud, sub- 
jected at first to neglect and later to opposi- 
tion, now are exerting an enormous influence in 
revising our conceptions of hysteria. The ex- 
haustive manner in which this Austrian studied 
his cases is remarkable. Not only have his ob- 
servations been a revelation of the importance 
of psychic insults in the etiology of the disease, 
and of the remarkable manner in which disso- 
ciated or submerged memory complexes dom- 
inate the hysteric, but they have been of the 
greatest consequence in showing how normally 
one's actions arid mode of thinking are largely 
determined by motives of which one is uncon- 
scious. 

In spite of the multitudinous volumes in 
which the disease, or certain of its symptoms 
and mental states are described, but few 
English books have appeared in which the dis- 
ease as a whole has been treated on the basis of 
the results of modern psychopathologic re- 
searches. In the belief that such a volume may 
not overburden the already great ranks of those 
dealing with the disease, the author has modestly 
attempted to meet this deficiency. In conclusion, 
this work is based upon, in fact is an exposition 
of, the modern conception of hysteria as enter- 
tained by the foremost contemporary students 



6 Psychopathology of Hysteria 

of abnormal psychology. A not inconsiderable 
amount of personal experimentation and clinical 
investigation has been drawn upon, and, not 
desiring the responsibility to rest upon the 
shoulders of others, it is necessary to ac- 
knowledge, also, that some personal views con- 
cerning the disease and its symptoms have been 
incorporated. 

Philadelphia, Pa. 



CONTENTS 

CHAPTER , PAGE 

Preface 3 

I Preliminary Considerations 11 

II Etiology 31 

HI Disturbances of Sensory Perception.. 56 
IV Disturbances of Sensory Perception : 

The Special Senses 89 

Y Visceral and Circulatory Derange- 
ments 136 

VI Psycho-Motor Disorders 173 

VII Psycholepsy 212 

VIII Alterations of Consciousness 268 

IX Multiple Personality and Amnesia.. 312 
X Hysteric Temperament, Suggestibil- 
ity, Delusions, Insanity, Theories . . 354 
XI Diagnosis, Prognosis. Treatment. .. . 394 



PSYCHOPATHOLOGY OP 
HYSTERIA 



PSYCHOPATHOLOGY 
OF HYSTERIA 

CHAPTER I 
Preliminary Considerations 

THE normal personality may be regarded 
as a highly mutable synthetic product 
of memories of past instruction and 
experiences as modified by present per- 
ceptions, either of external stimuli — exogenous 
— or of the countless number of various sen- 
sory impressions arising as a result of the activ- 
ity of the different structures of the body — 
endogenous or coenesthetic. By reason of the 
modifying influence of present external stimuli 
one's personality seems to undergo the greatest 
variation in accordance with the difference in 
his reactions to diverse environments; the mode 
of reaction suitable for one kind of environment 
being of pathologic import if displayed in an- 
other. As the memories of all experiences are 
fused with the personality, and as memories are 
never destroyed except by gross organic disease 
of the brain, every event in a person's life inevi- 
tably exerts an influence upon his individuality 
— upon his manner of reacting to his environ- 
ment. 

11 



12 Psychopathology of Hysteria 

In connection with the laws that "all nervous 
function is conditioned upon sensation/' and 
that all sensory impressions invariably become 
transformed into immediate or delayed move- 
ment, or action, W. K. Walker states: "That 
which is present in the mind at any given in- 
stant is therefore due to its past experiences; 
to previously experienced sensations, impulses, 
ideas, and emotions. These 'stored up' 'sensa- 
tions tend to final transformation into action' — 
that is, either action or restraint of action, — 
not only according to the laws governing all 
neural and mental manifestations in general, 
but, in particular, with the gradually acquired 
habit of reaction of the individual organism." 
(Med. News, Jan. 28, 1905.) 

By saying that we have forgotten something, 
we mean only that we are unable at the time 
to reproduce the memory — to raise the memory 
above the threshold of consciousness. In spite 
of our efforts to recall them, such memories re- 
main dormant only because we have been unable 
to obtain the proper association of ideas, and 
at any subsequent time reproduction can be 
effected, providing that the proper stimulus is 
called into play. Now, even though events have 
been "forgotten," still their dormant memories 
continue subconsciously to influence the actions, 
feelings, and mode of thinking of the individual. 
We act more or less in accordance with our feel- 
ings and our general conceptions, and though 






Preliminary Considerations 13 

we may forget in what manner these have been 
originated, yet the influence ofHhe underlying 
forgotten occurrences persists. One may not re- 
member just how the knowledge was first 
acquired that heat may cause pain, but the 
deficiency in our ability to reproduce these 
memories does not impair the value of a con- 
ception which has largely been the product of 
painful experience. 

The acquisition of knowledge, through personal 
experience, requires at first the conscious memory 
of particular causes and effects, but later, these 
details subside below the level of consciousness, 
unless the occurrence has been noteworthy, and 
only general conceptions remain. Consequently, 
my knowledge that fire may cause pain does not 
necessitate recollection of the many times when 
fire has caused me to experience pain. In this 
respect, then, a certain amount of submergence 
of memories is a normal concomitant of psychic 
development, and its value lies .in the freedom 
which it insures from being mentally en- 
cumbered with countless and useless facts. Ac- 
cepting as true these well known characteristics 
of the human mind we may conclude that, 
excepting possible hereditary factors and the 
effects of education, an individual's personality 
is of a certain nature, mainly because of the 
character of memories of countless experiences 
in which he has taken part; these memories, 
whether conscious or submerged, becoming 



14 PsycJwpathology of Hysteria 

integrals in the continual growth of the person- 
ality. 

It is for this reason that one evil act paves 
the way for another, and that no one can do 
wrong once with the intention afterwards to 
forget about the unpleasant act, and thus be 
free from harmful consequences. Each act or 
thought of an individual tends towards the 
recurrence of similar acts or thoughts — the 
production of a habit. In terms of materialism, 
this fact is explained as being the result of 
lowered synapsal resistance. Otherwise, a cer- 
tain kind of reaction having occurred in re- 
sponse to a given stimulus, we assume that, 
whether conscious or dormant, the memory of 
the experience largely determines repetition of 
the same reaction when a similar stimulus 
occurs. The economics of this tendency are 
easily grasped, for all forms of normally auto- 
matic activity are but examples of acquired re- 
flexes due to habitual modes of volition, and if 
it were not for such automaticity one's atten- 
tion would constantly be employed by the 
performance of the ordinary acts of life, at the 
expense of higher forms of activity and of 
acquisition of knowledge. 

To the normal process of forgetting, let us 
apply the term dissociation with the under- 
standing that this designation implies merely 
that though certain memories have subsided 
below the level of consciousness their influence 



Preliminary Considerations 15 

still persists in that they exert a continual ef- 
fect upon modes of thinking and of acting. In 
discussing this question Ernest Jones has writ- 
ten: "We are beginning to see man not as the 
smooth self-acting agent he pretends to be, but 
as he really is, a creature only dimly conscious 
of the various influences that mould his thought 
and action, ... " (Rationalization In 
E very-Day Life, Jour, of Abnormal Psych., Vol. 
3, p. 168.) No matter if one does think that 
he knows the mechanism and all the motives 
of any given act or thought, these have been 
originated or modified by memory complexes 
which are more or less completely dormant. 
Upon becoming acquainted with an estimable 
person, and without knowing the cause, one 
may experience towards him an "instinctive" 
dislike. Later, the true reason flashes into 
mind: it was because the object of aversion 
resembles another individual who had wronged 
him in some manner. 

If Ave should stop a moment to consider one 
of our most cherished ideas, perhaps we would 
not be able to recall the reasons which had led 
us to the adoption of that particular belief ; yet 
we know that there were a number of factors 
which determined its growth, and which con- 
tinue subconsciously to control us. Often we 
hear some one honestly make a positive asser- 
tion with all the assurance that would be war- 
ranted by thorough knowledge of the subject. 



16 Psychopathology of Hysteria 

Let a question arise concerning the grounds for 
his convictions and at once he is at a loss for 
data with which he can justify his assertion, 
even though he knows that formerly he was 
cognizant of these. 

Our supposed knowledge of the motives for 
our thoughts and actions is exceedingly super- 
ficial and illusory, and constantly we are the 
unconscious slaves of our past. In this sense, at 
least, we have not any freewill, and we are but 
the automata with superadded consciousness 
about which so much has been written ; reacting 
as we do to our present environment, according 
to the influence, more or less unconscious to us, 
of the past surroundings in which we have been 
placed merely as a matter of accident, as far as 
our own inclinations were concerned. In the 
last few years even more acceptably might have 
been written Spinoza's celebrated remark to 

the effect that " men think themselves free, 

inasmuch as they are conscious of their volitions 
and desires, and never even dream in their igno- 
rance, of the causes which have disposed them 
to wish and desire." (Ethica, Elmes trans.) 

To illustrate the agency of subconscious mem- 
ory complexes there is no better example than 
the "Frost King" episode in the case of Helen 
Keller. When twelve years of age Miss Keller 
wrote a story, which she called the "Frost 
King," and it was published in one of the 
Perkins's Institution Reports. Afterwards it 



Preliminary Considerations 17 

was discovered that this story was a duplicate 
in ideas — and in places even words — of another 
story which had been read to her three years 
before, or a little over one year after she had 
acquired the faculty of language — the sign lan- 
guage. Miss Keller was totally unable to re- 
member the original, and, until convinced by 
the facts of the case, she was equally positive 
that hers was entirely the product of her own 
mind. (The Story of My Life, 1903.) It must 
be remembered that this excellent instance of 
unconscious plagiarism is an unusually exag- 
gerated one, because of the limited amount of 
knowledge possessed at that time by Miss Keller, 
and because of the fact that by reason of cer- 
tain mental characteristics and of the difficulties 
under which she labored what she had once 
learned subsequently tended to almost complete 
reproduction, without, however, being coupled 
with the associated ideas of source. For this 
reason a thought might be considered by her to 
be original, when, in reality, it arose from her 
subconscious store-house of what had been read 
to her. The Hindoo cycle, in the case of Helene 
Smith, almost parallels the above occurrence 
both in the accuracy and in the unconsciousness 
of the plagiarism. (Flournoy: From India to 
the Planet Mars, 1901.) 

The tendency to unconscious plagiarism is not 
abnormal; nor is it unusual. Let one who is 
open to conviction read an authoritative book. 



18 Psychopathology of Hysteria 

If lie reads much, a year later he may be unable 
to recall the facts and theories which it con- 
tained, but, nevertheless, these continue to exert 
an influence in determining his own conceptions, 
though he may be unaware of the fact. A year 
or so later let him read the book again, and he 
will be surprised to find that beliefs which he 
thought not only were original but were of re- 
cent origin, were really derived from his first 
reading of the work. 

The following quotation from Hammond is a 
fine example of the activity of normally forgot- 
ten memories: "A friend has related to me 
some circumstances in his own case similar to 
the above, and illustrating the same points. In 
the course of his practice as a lawyer, it became 
necessary for him to ascertain the exact age of 
a client, who was also his cousin. Their grand- 
father had been a rather eccentric personage, 
who had taken a great deal of notice of both his 
grandsons — his only direct descendants. He died 
when they were boys. My friend often told his 
cousin that if his grandfather were alive there 
would be no difficulty at getting at the desired 
information, and that he had a dim recollection 
of having seen a record kept by the old gen- 
tleman, and of there being some peculiarity 
about it which he could not recall. Several 
months elapsed, and he had given up the idea 
of attempting to discover the facts of which he 
had been in search, when, one night, he 



Preliminary Considerations 19 

dreamed that his grandfather came to him and 
said: 'You have been trying to find out when 

J was born; don't you recollect that one 

afternoon when we were fishing I read you some 
lines from an Elzevir Horace, and showed you 
how I made a family record out of the work 
by inserting a number of blank leaves at the 
end? Now, as you know, I devised my library 
to the Kev. . I was a d — d fool for giv- 
ing him books which he will never read! Get 
the Horace, and you will discover the exact 
hour at which J was born. ' In the morn- 
ing all the particulars of this dream were fresh 
in my friend's memory. The reverend gentle- 
man lived in a neighboring city ; my friend took 
the first train, found the copy of Horace, and at 
the end the pages constituting the family 
record, exactly as had been described to him in 
the dream. By no effort of his memory, how- 
ever, could he recollect the incidents of the fish- 
ing excursion." (Sleep and Its Derangements, 
1869.) What is of particular interest in this 
case, is the fact that the dissociation was so 
complete that conscious recollection was impos- 
sible, yet complete synthesis was obtained dur- 
ing the dream. Furthermore, in the waking 
state, the lawyer was totally unable to recognize 
the personal nature of the memories which had 
been recovered. 

Now, let us suppose that independently of 
consciousness dissociated, or submerged, mem- 



20 Psychopathology of Hysteria 

ories become integrated with one-another, or 
that a massive dissociation of complexes from 
consciousness should occur, in consequence of 
some psychic insult, and that the dissociated 
fragment of what constituted the more or less 
normal personality took on activity irrespective 
of the present states of consciousness of the 
individual. Such processes naturally constitute 
pathologic disaggregation of personality, and 
if the offshoot were massive enough, a secon- 
dary personality would be produced. 

As a working hypothesis let us postulate 
that all the functional neuroses, or more prop- 
erly psychoses, are dependent upon disintegra- 
tion of personality, and that as such they are 
merely the result of pathologic exaggeration of 
what is a normal component of psychic devel- 
opment. Then neurasthenia, psychasthenia, hys- 
teria, and multiple personality would be clinical 
syndromes having a common origin; the under- 
lying disintegration being rudimentary in the 
first instance, more decided and often suspected 
even by the patient in the second one, still more 
developed and not surmised by patients suffer- 
ing with the ordinary types of hysteria, and 
massive enough to be complete in the condition 
known as multiple personality. 

By means of this prevalent and well founded 
hypothesis, almost every symptom of hysteria 
can be explained as satisfactorily as the mani- 
festations and pathologic changes of any organic 



Preliminary Considerations 21 

disease. Accordingly, amnesia results from ab- 
normally complete or massive dissociation from 
consciousness of certain memories, and the 
proof of its functional character can readily be 
adduced by means of reproduction of the lost 
memories through the agency of certain well 
known procedures. Anaesthesia, analgesia, amau- 
rosis, deafness, etc., would imply, on the other 
hand, that sensory perceptions had not become 
integrated with consciousness — that they had 
been appropriated, so to speak, by the dissociated 
components of the former personality. Experi- 
mentally, this explanation has been amply 
verified. 

After adducing experimental observations of 
Pierre Janet, Paul Janet, Binet, Pitres, and 
Bernheim, concerning phenomena of hysteria, 
no less authority than William James states: 
"It must be admitted, therefore, that in certain 
persons, at least, the total possible consciousness 
may be split into parts ivhich coexist but mutu- 
ally ignore each other, and share the objects of 
knowledge between them. More remarkable 
still, they are complementary. Give an object 
to one of the consciousnesses, and by that fact 
you remove it from the other or others. Bar- 
ring a certain common fund of information, like 
the command of language, etc., what the upper 
self knows the under self is ignorant of, and 
vice versa." (The Principles of Psychology, 
Vol. 1, p. 206, 1905.) 



22 Psychopathology of Hysteria 

At best, our knowledge of mental processes is 
superficial. Moreover, the difficulty of describ- 
ing normal and abnormal psychic phenomena is 
great. Any language necessarily must be a 
faulty vehicle for conveying the thoughts of one 
individual to another. A group of words is in- 
capable of reproducing in one person the exact 
conceptions of another. To this difficulty is 
added one's inability to describe briefly and 
accurately any process. Suppose we subject a 
remark to the same kind of criticism that would 
be attracted by the description of a mental pro- 
cess. By reason of poverty of words and in- 
exactness of verbal representation we say briefly 
that a cigarette is smoking, and that a man is 
smoking, or that the paper burns, and that he 
is burning the paper. In reality, the man neither 
smokes nor burns the paper, and, to say nothing 
of his own part in these acts, these phrases are 
most superficial and condensed representations 
of a variety of most complex chemical processes. 
In the same manner causation always must be 
obscure. What was the cause of destruction of 
the paper? The immediate one was oxidation. 
This was superinduced by heat which the man 
had applied. But then the endless chain arises 
concerning the causes of the man wishing to 
destroy the paper that was not destroyed, but 
whose chemical components were merely disso- 
ciated, to be recombined in a different manner 
and with the addition of oxygen. 



Preliminary Considerations 23 

In describing the psychic mechanism of hys- 
teria we say that the disease is caused by disso- 
ciation of consciousness, and that this process 
causes increased suggestibility, then, in the next 
breath, that further dissociation may result as 
the effect of this symptom. These statements 
only imply, however, that a vicious circle is 
formed. The same process is apparent in the 
use of hypnotism. By means of suggestion a 
subject is hypnotized. The increased suggesti- 
bility produced by this state of dissociation then 
enables us to induce more readily further disso- 
ciation. 

Two individuals being exposed to the same 
psychic stress, one may develop hysteria, and 
the other psychasthenia ; the difference in the 
two syndromes being equivalent to difference in 
the modes of feeling, thinking, and acting of 
the two persons. The condition of the one who 
developed psychasthenia is said to be due to 
dissociation of the personality and that as a 
consequence, fear and expectant attention appear 
as symptoms. Then, like the vicious circle of 
hysteria, these symptoms, by causing further 
dissociation, induce various other phenomena. 

In a gross materialistic way the pathologist 
is satisfied when, with the assistance of stains, 
microscope, and other laboratory apparatus, he 
finds that certain lesions occur more or less con- 
stantly in some disease. He seems to be con- 
tented with this knowledge — he has discovered 



24 Psychopathology of Hysteria 

the cause of a disease — yet the discovery of 
these lesions does not explain the cause for the 
same reason that dissociation of personality does 
not account for the production of the psy- 
choneuroses. There is an inherent tendency for 
one to believe that he knows much about a dis- 
ease merely because he possesses some knowledge 
of the anatomical changes which are really con- 
comitants or secondary causes. To say that 
lesions of the islands of Langerhans are the 
cause of diabetes does not explain the disease. 
Not only is there a cause, or causes, for this 
sclerosis, but there may be a whole succession of 
pathological processes that precedes its develop- 
ment. The greater part of pathology consists 
only in a superficial knowledge of terminal pro- 
cesses, and the only advantage it has over psy- 
chopathology is that scales, test tubes, and a 
microscope lend an aspect of scientific precision 
which cloaks in a satisfactory manner our real 
ignorance of causality. In spite of what the 
materialistic pathologist would have one believe, 
psychopathology is not entirely a matter of 
groundless theories based upon the morbid in- 
trospection of deviates. With the assistance of 
association reaction time experiments, the psy- 
chogalvanic reflex, pulse reactions, etc., the psy- 
chologist can "measure" the emotions and de- 
tect and reveal subconscious ideation. 

In the early studies of hysteria, and, in fact, 
even to the present, it was customary to describe 



Preliminary Considerations 25 

a number of symptoms as characteristic, or stig- 
matic, of the disease. Among the most import- 
ant were anaesthesia and concentric contraction 
of the visual fields. We are beginning to under- 
stand, now, that these "stigmata" are only ac- 
cidental phenomena, which, except when created 
by reason of faulty methods of examination, are 
rather unusual if not rare. It was only by rea- 
son of the suggestive technique of the ordinary 
examination that, until recently, the occurrence 
of "stigmata" was so common. 

The recent discussion of hysteria before the 
Paris Neurological Society brought out the quite 
general recognition of the fact that the symptoms 
of the disease, as many have intimated for years, 
are caused by suggestion, and that what have 
been called the stigmata usually owed their 
origin to examinations by physicians who dis- 
regarded, or were unaware of, the effects of sug- 
gestion in causing the conditions which they 
sought. Certain members averred that by at- 
tempting to avoid the pathogenic effects of sug- 
gestion during their examinations of hysteric 
patients, they no longer find anaesthesia and the 
like, provided that the patients had not been 
examined previously by others. In fact, the 
tendency of some of the members seems to have 
been to ascribe to suggestion all the symptoms 
of the disease. According to Babinski, for in- 
stance, a patient is not hysteric whose symptoms 
are incapable of being reproduced by suggestion 



26 Psyclwpathology of Hysteria 

and removed by persuasion. Yet Babinski was 
one of those who formerly opposed the conten- 
tions of Bernheim, to the effect that the stigmata 
of hysteria are merely the product of suggestion. 
Consequently, his present views possess greater 
significance than if he had upheld the theory 
from the beginning. 

If it is desirable to establish stigmata of 
hysteria let us confine ourselves to the only 
symptom which is characteristic of the disease. 
The only one whose presence is at all constant, 
and whose pathogenic importance cannot be 
overestimated, is pathologic increase in sug- 
gestibility. This veritable stigma has been a 
prolific cause of blunders in the past studies of 
the disease. It is by reason of its agency that 
any enthusiastic investigator ordinarily and un- 
intentionally can cause whatever he may wish 
to find in support of his views ; no matter what 
these may be. Thus, one can appear to demon- 
strate that the symptoms of hysteria are due 
only to intentional simulation, or that any 
symptom is essential to the existence of the 
disease. At la Salpetriere, for instance, there 
was created a typical epidemic of hysteric con- 
vulsions which influenced for years the study 
of hysteria, and which was the effect solely of 
an elaborate suggestive training and of psychic 
contagion. 

Since Bernheim 's recognition of the danger 
of misinterpretation of the occurrence of symp- 



Preliminary Considerations 27 

toms of hysteria through the more or less un- 
conscious use, or rather abuse, of suggestion by 
the observer, the understanding of the disease 
has advanced considerably at the expense of 
numerous theories and classic experiments 
which owed their very existence to suggestion. 
Many years elapsed, though, before the full sig- 
nificance of the well known cautionary "be- 
ware of suggestion" of this pioneer became ap- 
preciated. The delay was due to the power- 
ful antagonism exerted by Charcot in conse- 
quence of his total disbelief in the effects of 
suggestion. In fact, the experiments of Char- 
cot and his followers upon hysteric patients 
were rendered valueless by reason of their dis- 
regard of suggestion. To no other factor than 
ignorance of the possibilities of suggestion can 
be ascribed the ludicrous experiments and 
theories of Luys,* and others of the Salpetriere 
school, concerning the wonderful effects of 
magnets, of metals, and of medicine in sealed 
glass tubes. 

It has been demonstrated conclusively, that 
because of this increased susceptibility to sug- 
gestion, so invaluable for therapeutic purposes, 
prolonged, unnecessary, and repeated neuro- 
logic examinations of hysterics, their associa- 
tion with other victims of the disease, and their 
demonstration before clinics, where they hear 



(•Reported and exposed by Ernest Hart in Hypno- 
tism, Mesmerism and the New Witchcraft, 1896.) 



28 Psychopathology of Hysteria 

descriptions of their symptoms and of the dis- 
ease, both create symptoms and prolong those 
already in existence. Therefore, one can read- 
ily appreciate that the earnest and faultily con- 
ducted studies and the clinical exploitation of 
these cases formerly was responsible for an 
incalculable and irreparable amount of injury. 

Recognizing the importance of increased 
suggestibility in producing symptoms, we can 
commonly interpret the classic stigmata as arti- 
ficial creations. As such, they have almost as 
much diagnostic value as formerly; providing 
that their production, which usually cannot be 
considered justifiable, is thought necessary. 
Then, too, the acceptance of these views leads 
to a better understanding of the symptoma- 
tology of hysteria, and, furthermore, we will 
have advanced one step in the pursuit of the 
first cause. 

With the justification afforded by the con- 
ceptions of the modern French neurologists, as 
briefly indicated in these few prefatory notes, 
the symptomatology of hysteria will be largely 
considered upon a basis of suggestion, and the 
effects of the abnormally great suggestibility in 
creating or in modifying symptoms intention- 
ally will be reiterated with the purpose of call- 
ing attention to the possibilities of unconscious 
abuse of this characteristic of the disease. 

A fact which must be borne in mind, one 
which a priori must be true, is that each per- 



Preliminary Considerations 29 

son's hysteria must differ just as the mental 
characteristics of all individuals vary. More- 
over, the kind of symptoms possessed by a 
patient depends entirely upon the nature of 
the incidental exciting causes, upon the per- 
sonal equation, upon psychic contagion from 
others, and upon the effects of accidental sug- 
gestion. 

Bernheim believes that it is impossible to de- 
iine hysteria because it is hot a morbid entity. 
According to Lasegue hysteria never has been 
denned and it never will be. In a more hope- 
ful spirit Grasset does not despair of any 
progress, but he believes that the definition is 
still impossible. In spite of the restrictions of 
these, and other neurologists, the definitions of 
hysteria, like those of insanity, are almost as 
numerous as the writers who have described 
the disease. Having the sanction, then, con- 
ferred by numerous precedents, and recognizing 
the impossibility to define satisfactorily such a 
protean malady, the following may be regarded 
merely as a provisional definition: 

Hysteria may be designated a psychoneurosis, 
or so-called functional nervous disease, which, 
tending to develop particularly in those predis- 
posed by neuropathic heredity and by vicious en- 
vironment, is dependent upon disintegration of 
personality and is characterized by symptoms 
originating from the morbid control of the 
body by subconscious states; whose symptoms 



30 Psychopathology of Hysteria 

can be shown to be but exaggerations or per- 
versions of normal modes of feeling, of think- 
ing, and of acting; a disease which is distin- 
guished by a peculiar type of temperament, 
faulty adaptability to environment, pathologic 
increase in suggestibility resulting in the liability 
to develop many kinds of phenomena, and the 
possibility of the appearance of any one or 
more of a vast number of " accidents " arising. 
from morbid ideation. 



CHAPTER II 
Etiology 

HEREDITY. In common with the other 
psychoneuroses, hysteria is thought 
usually to occur in those whose nervous 
system is rendered, as a consequence 
of neuropathic heredity, more susceptible than 
usual to functional derangement. Undoubtedly 
this is true, but the occurrence of hysteria does 
not necessarily always imply the instrumental- 
ity of heredity, or the existence of a state of 
organic nervous degeneracy. In fact, the family 
history is above reproach in about 10% to 20% of 
cases of hysteria. If one accepts the extreme views 
upon degeneration promulgated by Nordau* 
and others, then but few families could be con- 
sidered entirely free from some variety of 
hereditary psychopathic taint. 

It is best, therefore, to entertain conserva- 
tive views about this matter and to limit our 
conception of the influence of neuropathic he- 
redity to those cases in which a history of 
epilepsy, insanity, dipsomania, or distinct crim- 
inal tendencies can be found in the immediate 
ancestry. 

Direct inheritance of hysteria may be possi- 
ble, but the more apparent deleterious effects 

•Degeneration, 1897. 

31 



32 Psyehopathclogy of Hysteria 

of constant association of the offspring with a 
hysteric parent is sufficient to account for those 
instances in which the disease is encountered in 
two consecutive generations of a family. 

A broad minded view of the part played by 
heredity in the production of hysteria is to hold 
the opinion that the disease is potential in 
every one, and that the potentiality becomes 
more decided when neuropathic heredity exists. 
Then the relationship between hysteria and 
direct heredity is practically the same as that 
in tuberculosis; direct inheritance of either 
disease being rare, and the usual character of 
transmission being that of increased suscepti- 
bility. The aptness of this comparison becomes 
more evident if one stops to consider the many 
families in which, despite the existence of psy- 
choneuroses in the parents, the children present 
merely a nervous type of temperament, which 
is not decided enough to be regarded patho- 
logic. 

The potentiality of the disease in every one 
may be likened, also, to the general suscepti- 
bility to its analogue, hypnotism. With the 
exception of the insane and of the psychas- 
thenics, whose peculiar mental state renders 
hypnosigenesis difficult, but not impossible, as 
Janet asserts, about 90% of people are capable 
of being hypnotized ; our failure to succeed with 
the remainder probably being due to lack of 
patience, and, when the attempt is not made 



Etiology 33 

for therapeutic purposes, to the absence of a 
good reason for its induction. 

Environment. Those who have to deal 
with the psychoneuroses hear the complaint 
constantly that nervousness has been engen- 
dered, as well as aggravated, by that of those 
with whom the individual has been in constant 
association. It is usually the continual irrita- 
tion, and the state of expectant attention, or 
auto-suggestion, which is induced by the pro- 
pinquity of hysteric parents that increases the 
liability of the progeny to develop the disease. 
Then, having developed, heredity receives the 
blame. Under the caption psychic contagion 
the influence of environment will receive fur- 
ther attention. 

Faulty Education. As hysteria is com- 
monly disposed to attack those who have not 
acquired sufficient emotional stability, self- 
control, and the proper appreciation of the rela- 
tion between self and the outside world, any 
system of education which is deficient in devel- 
oping these qualities may lead to the produc- 
tion of the disease. 

The pernicious effect of over indulgent par- 
ents is great. Faulty conceptions of external 
relations and faulty modes of reacting to other 
environments are produced, and these, together 
with the effects of the parent's habitual disre- 
gard of emotional outbursts, constitute a kind 
of temperament which cannot be other than 






34 Psychopathology of Hysteria 

conducive to hysteria — if not already a feature 
of the disease. Few, indeed, are the " spoiled " 
children who are unselfish, whose tempers are 
reasonably controlled, and who are capable of 
developing into self-reliant men and women! 
Fortunate are the children of the poor in that 
they are less apt to be the recipients of such 
undesirable attentions! 

Let not the impression be gained from these 
sentences that hysteria is most frequent in 
children. The child is father of the man, and 
as the adult's temperament and mode of reac- 
tion is the outcome of that of the child, early 
educational methods are of the greatest impor- 
tance either in the causation or in the pro- 
phylaxis of psychoneuroses. 

Age. The emotional disturbances charac- 
teristic of pubescence, and the unstable psychic 
equilibrium of maturity, the period of great- 
est exposure to the stresses of life, naturally 
favor the onset of hysteria. This is shown by 
the following table constructed from a dispen- 
sary service from which patients younger than 
15 .years were excluded; these cases being 
treated in another department : 
Age. 15-20 25 30 35 40 45 50 55 60 65 
% 23 13 11 17 10 5 8 6 5 2 

Sex. Because of their inherent emotional- 
ism and relative inferiority in logical reasoning 
and philosophical acceptance of the various 
inevitable stresses of life, females are more sus- 



Etiology 35 

ceptible to hysteria than are males. The dif- 
ference in the incidence of the disease in the 
two sexes is explained by Ziehen as being due 
to the fact that the psychic reactions which nor- 
mally characterize the female sex closely re- 
semble those essential to hysteria. (Modern 
Clinical Medicine, Diseases of the Nervous Sys- 
tem, p. 1048, 1908.) It is the absence, too, of 
the hardening effects of the greater responsi- 
bilities, which are shouldered by men, that is a 
great factor in producing this inequality. 

Even more unreliable than usual are the sta- 
tistics concerning hysteria. As all the psy- 
choneuroses are only clinical syndromes de- 
pendent upon the same psychic abnormality 
— disaggregation of personality — it is impossi- 
ble for neurologists to come to an agreement 
over the disposition of the borderland cases. 
However, most stimulating to progress in the 
study of this great and important group of dis- 
eases is the difference of opinion concerning 
their classification. The personal element enters 
so largely into the collection of these statistics 
that, according to the difference in their concep- 
tions of hysteria, various statisticians have col- 
lected figures which vary as much as 50%. 
With this qualification, then, which applies also 
to the other figures in these pages, the ratio of 
hysteria in males and females lies between 1 to 
3 and 1 to 6. Careful examination of the rec- 
ords of 100 consecutive cases of hysteria, to- 



36 Psychopathology of Hysteria 

gether with revision of the diagnosis when this 
was considered necessary, showed that 25% of 
the cases were males. 

Among males, by no means is it the effemin- 
ate man who is most apt to develop hysteria. 
Experience shows that the disease attacks more 
frequently the hard working and often prosaic 
man; the reason being that in males the mani- 
festations almost invariably follow traumatism, 
and, consequently, those men who are most ex- 
posed to physical injury are the ones most 
liable to develop hysteria. Both for this reason, 
and on account of the less dangerous occupa- 
tions followed by women, traumatic hysteria 
occurs more frequently in men. A noticeable 
feature of the disease in men is its severity, 
and its tendency towards what appears to be 
monosymptomatic expression; such manifesta- 
tions as paralysis, mutism, and psycholeptic at- 
tacks being the ones most commonly observed. 

Social Factors. Though the relatively de- 
ficient amount of education possessed by the 
rural population and the hard working poor of 
the cities renders them more susceptible to the 
acute epidemic form of the disease they are less 
inclined to be subject to essential hysteria than 
those of the upper urban classes. The com- 
parative freedom of the former is due to the 
fact that they escape the over refining influ- 
ences of a life of idleness, emotionalism, and 
luxury, and that their psychic equilibrium is 



Etiology 37 

rendered more stable by what usually is not an 
abnormal amount of responsibility. Other im- 
portant reasons for this difference are afforded 
by the more self-reliant manner in which their 
children are brought up, and by the fact that 
the greater freedom of these children causes 
them to be less exposed to psychic contagion in 
case one or both parents are neurotic. Then, 
too, the fact that the poor marry early pos- 
sesses significance in that it lessens materially 
the exposure to a certain kind of emotional 
stresses whose importance in the etiology of 
hysteria has been shown to be too great to be 
ignored. 

As the dregs of the city community is com- 
posed of individuals who follow lives of in- 
ordinate excitement and whose passions are un- 
accustomed to self-restraint, and as this social 
element contains an undue proportion of the 
truly degenerate, hysteria is not only frequent 
but it is encountered in its most highly elabor- 
ated forms. The disease is most common, there- 
fore, in the extremes of society. 

Occupation. Certain occupations are attend- 
ed with an increased liability to the develop- 
ment of hysteria because of the emotionalism 
and unsettled mode of living that they ne- 
cessitate. Particularly is this the case when 
an imaginative or artistic, one might almost 
say hysteric, temperament is one of the requis- 
ites. Thus, artists, musicians, authors, and 



38 Psyehopathology of Hysteria 

members of the dramatic profession, are fre- 
quently attacked by the disease. The excessive 
anxiety and alternation of intense emotions en? 
tailed by the character of their occupation in- 
creases the predisposition of stock traders and 
others whose fortunes are largely dependent 
upon chance. 

Race. As the French were the first to study 
extensively and to write about hysteria, it was 
formerly thought that this disease was en- 
countered but rarely outside of France. Since 
physicians of other countries have become better 
acquainted with hysteria, and thus are able to 
differentiate its major manifestations from those 
of other diseases, this erroneous idea has dis- 
appeared. Because of their emotional tem- 
perament, however, the condition probably is 
more prevalent and more highly developed in 
people of the Latin races. 

Although infrequent as a distinct endemic dis- 
ease, epidemics of hysteria, usually of a religious 
nature, are not uncommon among the uncivilized. 
Indeed, symptoms of hysteria are frequently ob- 
served in connection with the religious ceremo- 
nies of savages, and these manifestations may be 
the true source of certain religious beliefs. 

Climate. — Hysteria is more frequent in 
tropical countries because these are inhabited 
mainly by the Latin races. The mental effects 
of a new environment and of the physical dis- 
comfort caused by an unaccustomed amount of 



Etiology 39 

heat, together with the stimulating effects upon 
emotional activity of this relatively excessive 
heat, results in the production of an unusual 
number of cases of psychoneuroses among North- 
erners who have emigrated to the tropics. 
Americans residing in the Philippines seem to 
be particularly prone to develop neurasthenia. 
According to Louis H. Fales "nearly all Amer- 
ican women and a large proportion of men who 
have been in the Islands one year or more suffer, 
at least to some extent, with nerve exhaustion. It 
is conservative to state that 50% of the women 
and 30% of the men suffer with neurasthenia to 
such an extent that they are in a state of semi- 
invalidism." (Amer. Jour, of the Med. Sciences, 
1907, vol. 1, p. 583.) 

Exciting Causes. The exciting causes may 
conveniently be divided into acute psychic insults 
and chronic mental stresses. 

Acute Psychic Insults. — Traumatic hysteria 
should be considered the result of the acute 
mental shock of an accident and not the 
physical effect of traumatism. For instance, 
even though hysteric paralysis should appear in 
a limb immediately after it has been injured, ex- 
perimentally it can be proven that the paralysis 
is entirely psychic in nature, and, therefore, un- 
der certain conditions the affected part can be 
used in a manner that does not differ from the 
normal. Indeed, if such were not the case the 
paralysis would not be symptomatic of hysteria. 



40 Psychopathology of Hysteria 

Consequently, the direct physical effects of the 
injury are not instrumental either in producing 
or in maintaining the condition. 

Even though not any symptoms of the disease 
had ever before been apparent theoretically any- 
one may develop a simple physical manifes- 
tation of hysteria, or even a more elaborate 
form of the disease, as the immediate or de- 
layed consequence of a severe or trivial acci- 
dent. In quite a few cases symptoms first 
appear after a surgical operation. Like the 
ones following traumatism these do not result 
from the physical effects of the operation but 
rather from the anxiety, actual pain, and other 
distressing features of what is a novel ex- 
perience. Often the manifestations of these 
post-operative cases are elaborated from the or- 
ganic symptoms for which the patients were op- 
erated, or from the transient ones occasioned by 
the operation, or the surgical anaesthesia. In 
this manner various pains, anorexia, vomiting, 
tympanites, urinary retention, and other symp- 
toms may be prolonged through the agency of a 
complicating hysteria. 

Other than those resulting from physical 
traumatism probably the majority of cases of 
acute development are due to psychic insults 
whose nature is more obvious. To this large class 
belong the ones following sudden disappoint- 
ment, deaths, and illness in others, or in 
self. The emotional perturbations arising from 



Etiology 41 

tumultuous affaires du coeur, or from oues 
which have resulted in disappointment, are pro- 
lific exciting causes of hysteria. Any relatively 
severe emotional shock, however, is capable of 
acting as an exciting cause. 

Though the onset of hysteria may appear to be 
gradual, yet, upon investigation, it will often be 
found that the underlying disintegration took 
place suddenly, and perhaps even that it ante- 
dated by weeks or months the appearance of 
symptoms; this ''period of incubation" having 
been appropriately designated the period of 
meditation, or of auto-suggestion. Usually, the 
more acute the onset the more typical and severe 
are the manifestations and the less complicated 
by neurasthenic symptoms is the resulting symp- 
tom complex. Such cases, too, are more amen- 
able to treatment, and, after recovery has taken 
place, there is less tendency towards recurrence. 

Chronic Mental Stresses. The many possible 
chronic exciting causes are inseparable from 
predisposing factors. They include such diverse 
conditions as prolonged illness, chronic organic 
diseases, and any kind of long continued emo- 
tional strain such as induced, for instance, by 
familial and marital difficulties. 

The development of hysteria in those afflicted 
with organic disease often is most misleading to 
the diagnostician. It is easy to comprehend how 
the knowledge that one is afflicted with a severe, 
incurable, organic malady, together with the 



42 Psychopathology of Hysteria 

mental effects of what may be distressing physi- 
cal symptoms, is most conducive to the gen- 
eration of a superimposed hysteria. In epilepsy, 
for instance, how frequent is the interposition of 
typical epileptiform seizures of hysteric origin! 
Many, too, are the cases of multiple sclerosis 
which are complicated by hysteria. 

Toxemia. In harmony with the theory that 
brain cells secrete thought it has been con- 
tended that the psychoneuroses are directly 
caused by the deleterious effects upon the nerve 
cells of autogenic toxins. Also that ingestion 
of toxic substances is capable, in the same man- 
ner, of producing these conditions. Experience 
shows, however, that while auto-intoxication is 
quite common in neurasthenia and psychasthe- 
nia, it is not frequent in cases of hysteria. In 
view of the fact that in but few cases of the pure 
forms of hysteria can any evidence of toxsemia 
be found, another view of the mechanism of pro- 
duction not only is possible but is a necessity. 
Granted that toxins may exert a direct effect 
upon nerve cells, does not this act only as a pre- 
disposing factor in the majority of cases appar- 
ently due to toxaemia ? It is easy to conceive, of 
a heightened susceptibility to hysteria as a re- 
sult of the state of mental depression caused by 
a chronic auto-intoxication. It is too much to 
expect any one to feel well whose head aches and 
who experiences vertigo and other unpleasant 
symptoms as consequences of toxaemia from 



Etiology 43 

gastrointestinal disturbance. The state of men- 
tal depression resulting from a condition of 
chronic intoxication only decreases cerebral in- 
hibition so that in the presence of an adequate 
exciting cause hysteria can develop more readily 
than otherwise. 

A common error is to ascribe to the etiology of 
hysteria the not uncommon autotoxis due to 
gastro-intestinal derangements which, in reality, 
are secondary effects of hysteria and not the 
cause of the disease. One has only to remember 
the effects of emotional states upon digestion, as 
shown by Pawlow, Cannon, and others, to under- 
stand how auto-intoxications can occur as com- 
plications of hysteria. 

As an exciting cause of hysteria the mechan- 
ism of toxaemia might be compared with the 
mode of production by drugs of hallucinations 
and delusions. No one knows just how or why 
a drug or a toxin acts upon the brain, but we 
do know of the extreme variations in the cere- 
bral effects of these substances. We have good 
reason to suspect that the delusions and halluci- 
nations that may occur during certain drug in- 
toxications are produced reflexly, and, therefore, 
that they are secondary to the effect of the drug 
upon cerebral inhibition. As such they are com- 
pletely the analogues of the delusions and hallu- 
cinations of dreams. 

Let us say that a drug does not directly cause 
a delusion but that it merely diminishes cerebral 



44 Psychopathology of Hysteria 

inhibition, and thus permits lower forms of re- 
flex cerebration whose nature is largely depend- 
ent upon the character of the coenesthetic im- 
pressions and of the chance external stimuli 
which are perceived at the time. Furthermore, 
such mental activity necessarily must be based 
upon the character of previous environment and 
education. 

An intoxicated man reacts to his environment 
in a manner that is more or less completely de- 
void of the control of cerebral inhibition. Conse- 
quently, his actions are better standards of his 
true character than are those when he is sober 
— when he has assumed his mask. One cannot 
reasonably assert that alcohol so acts upon the 
brain ceils that an intoxicated person is rendered 
pugnacious, or boisterous; it is more probable 
that these manifestations are revelations of the 
individual's real character undisguised by cere- 
bral inhibition. 

After taking opium a commonplace man might 
experience sleep, which, as far as he was after- 
wards aware, was dreamless, while a brilliant 
thinker like De Quincy or Coleridge would un- 
dergo, with or without the production of sleep, 
the most exhilarating and lucid forms of intel- 
lectual activity. Or, quite commonly the admin- 
istration to a nervous patient of certain hypno- 
tics not only may be devoid of any tendency to 
produce either dreams or sleep, but it may lead 
to aggravation of the symptoms for which it 
was given and to the production of new ones. 



Etiology 45 

The theory advanced by Obersteiner and 
Pry or that sleep results from the accumulation 
of toxic matter is analogous to the theory that 
hysteria is the outcome of a similar condition. 
As the result of his experimental study of sleep 
Sidis concludes that the state "is not a disease, 
it is not, as the chemical speculators would have 
it, a kind of narcosis of the system by the poisons 
of fatigue products" but that it is "an actively 
induced passive state in relation to the external 
environment " (Jour, of Abnormal Psychology, 
vol. 3, p. 189.) Biologically interpreting sleep 
as an instinctive reaction of defense, Claparede 
avers that we sleep not because we are in- 
toxicated or tired, but in order not to be so. 
(Archives de Psychologie, Feb. and Mar., 1904.) 

The strongest argument against the hypothesis 
that in consequence of the direct effects of the 
toxins upon the structure of the nerve cells 
toxaemia is a cause of hysteria is the fact that 
many cases occur suddenly after accidents and 
in the absence of toxaemia, and also that practi- 
cally every symptom of the disease can be dupli- 
cated so veritably by hypnotic suggestion as to 
deceive an expert. Naturally the whole subject 
revolves around the ancient and ubiquitous prob- 
lem of the relation between brain and mind; the 
time honored question of monism and dualism. 

Psychic Contagion. Not only is psychic 
contagion important as a predisposing cause 
but its significance in the actual production 



46 Psychopathology of Hysteria 

of hysteria cannot be emphasized too greatly. 
The influence of psychic contagion is par- 
ticularly noticeable in children on account of 
their normally great susceptibility to suggestion; 
the suggestibility which is the cause of their in- 
herent tendency to imitate, and which enables 
them to acquire knowledge easily by reason of 
the ready acceptance, to which it leads, of any 
statement made by one in whom they have con- 
fidence. 

Quite commonly, indeed, children are en- 
countered who present accidents of hysteria 
identical in character with those of their parents. 
I can recall a typically hysteric woman who had 
psycholeptic attacks simulating focal elipepsy 
whose child, after witnessing a number of these 
seizures and hearing his mother describe the 
symptoms of which she was conscious, developed 
similar crises. Even the aura and the march of 
the symptoms were duplicated. In fact, the 
crises of more than 25% of cases of psycholepsy 
can be traced directly to similar attacks which 
the patients have observed in others. In another 
instance all the children of a large family pos- 
sessed gastric symptoms like those of their 
father 's ' ' gastric neurosis ' ' in addition to cardiac 
symptoms that they had acquired by psychic 
contagion from observing their mother's heart 
attacks. 

Among school-children, in hospital wards, and 
in dispensary clinics, the effects of psychic coa- 



Etiology 47 

tagion are frequently encountered. Particularly 
is this true of large clinics where many cases 
of psychoneurosis have the opportunity to com- 
pare symptoms, to observe the physical disabili- 
ties of those afflicted with organic nervous dis- 
eases, and to hear lectures concerning neurologic 
subjects. One patient who had been treated for 
epilepsy heard a description of the procursive 
variety of epileptic attack during a clinic of which 
he was the subject. In less than a week procur- 
sive seizures developed like those whose descrip- 
tions he had heard. This led to question of the 
diagnosis, and, after close study, it was found 
that his seizures were hysteric in origin. 

Another patient who was supposed to be an 
epileptic, though there was good reason for re- 
garding his attacks as being symptomatic of 
hysteria, acquired a lot of new symptoms of 
which he made complaint during the first visit 
after having been examined by students in a 
clinic. All of these new conditions were ones 
whose presence had been sought, and their genesis 
was due to the suggestive manner in which 
inexperienced students had conducted their 
tests. Even the most carefully conducted ex- 
aminations, however, may be followed by psycho- 
genetic symptoms. Kecognizing this fact Gowers 
stated that: "Medical inquiries and examina- 
tions often suggest to patients the definite ideas 
of symptoms, and the physician's knowledge of 
the natural association of symptoms may thus 



48 Psychopatkology of Hysteria 

lead to their consistent grouping in a mimetic 
malady, even when there is not, and still more 
when there is deliberate simulation. ' ' (A 
Manual of Diseases of the Nervous System, p. 
989, 1903.) 

In addition to abnormally great hetero-sugges- 
tibility psychic contagion resulting from patho- 
logic auto-suggestibility — expectant attention — 
naturally has interfered greatly with the proper 
interpretation of the incidence of certain symp- 
toms, and has been the sole cause of the appar- 
ent verification of many otherwise baseless theo- 
ries of the disease. 

The dabbling with spiritualism of the less in- 
telligent is an especially pernicious factor both in 
predisposing to hysteria and in producing the 
disease. For obvious reasons it is usually the 
credulous, emotional, imaginative, and highly 
suggestible person who attends seances and who 
believes in the supposed evidences of spirit con- 
trol which he witnesses, and as there are many 
manifestations of hysteria among these pheno- 
mena he is fortunate if he does not acquire some 
by psychic contagion. 

More harmful are attempts to become me- 
diumistic. When an individual deliberately 
seeks and encourages the development of self- 
induced, organized, mental dissociations, such as 
those required by trance states, automatic writ 
ing, etc., he is but creating and evolving a 
tendency that subsequently may escape his con- 



Etiology 49 

trol and become the foundation of actual 
hysteria. Even the successful self-induction of 
these conditions might be considered with good 
reason proof of hysteria. 

Because spiritualistic enthusiasts have wit- 
nessed so many diverse manifestations of hys- 
teria, and because quite commonly they are 
well posted in a spurious form of psychology, or 
rather abnormal psychology, if hysteria develops 
there is at hand a wealth of knowledge of 
pathologic symptoms upon which autosugges- 
tion can operate in the production of a most 
completely developed type of hysteria; one in 
which the disease is expressed less physically 
than as a psychosis. By reason, too, of their 
pseudo-knowledge of transcendental psychology, 
philosophy, and metaphysics, spiritualists and 
Christian Scientists are most resistant to psycho- 
therapy, and their very knowledge prevents the 
successful application of other forms of treat- 
ment. 

Epidemic Hysteria. When widespread, psy- 
chic contagion may cause veritable epidem- 
ics of what is regarded by some as hysteria, 
and by others as hypnotism. Frequently this 
occurred in the Middle Ages, and even at pres- 
ent the tendency has not entirely disappeared. 
A wave of epidemic religious hysteria has been 
known to sweep over an entire race and to con- 
tinue until interest either died out naturally or 
until it was directed to some other object. 



50 Psychopathology of Hysteria 

The ghost-dance religion of our own Indians 
is an excellent example of an epidemic of 
psychic contagion in a partially civilized peo- 
ple. This epidemic is particularly interesting 
in that it has been reported so carefully by 
James Mooney. (Fourteenth Annual Report 
of the Bureau of Ethnology, Smithsonian In- 
stitute, Part 2, 1892-93.) Incidentally, the 
manifestations of epidemic hysteria among sav- 
ages are often identical with those which have 
occurred during many similar epidemics among 
highly civilized people. 

Epidemics of hysteria have usually assumed 
a religious character because, of belief in the 
supernatural entertained by those who were 
affected. Through lack of intelligent appre- 
hension certain accidental phenomena may be 
ascribed to supernatural agencies with the" re- 
sult that abject fear, together with the in- 
creased suggestibility characteristic of mobs, 
leads to the birth of an epidemic. Those who 
are most liable to become subject to these in- 
fluences are the credulous, the superstitious, 
and the impressionable ; ones who are incapable 
of thinking for themselves and who are de- 
pendent upon others for guidance. In modern 
times epidemics of hysteria have usually 
assumed the form of revivals, and have oc- 
curred mainly among the impressionistic and 
highly superstitious negroes and Indians. The 
best example of a comparatively recent epi- 



Etiology 51 

demic among intelligent people was the de- 
plorable New England witchcraft episode. 

When hysteria becomes epidemic it cannot 
be considered other than an acute transitory- 
form that reveals the inherent potentiality of 
the disease in all people. Not infrequently epi- 
demics occurred in convents, and as in these 
instances the number of those exposed was 
limited, the ubiquity of the potentiality is re- 
vealed more fully. In such epidemics not a 
few, but the majority, if not all, of the inmates 
were affected. The effect of repression of the 
sexual instinct was a conspicuous feature of 
epidemics involving the occupants of convents; 
the disease being expressed mainly by what 
was termed demoniac possession of which a 
frequent symptom was delusions of sexual in- 
tercourse with evil spirits. Since the exposi- 
tion of Freud's theories of hysteria the signi- 
ficance of this fact can be grasped more intelli- 
gently. 

Man tends to explain to the best of his ability 
phenomena of whose nature he is ignorant. If 
he believes in demons, and if he has no other 
more plausible explanation, he accounts for cer- 
tain unusual incidents by assuming that they 
result from diabolic agencies. If such views of 
an individual receive popular acceptance, or 
if they are prevalent ones of the age, an epi- 
demic of demonophobia may be the outcome. 
In the study of vampirism, demonophobia, 



52 PsychopathoLogy of Hysteria 

witchcraft, and the like, we have to deal actually 
with two interdependent epidemics; one of abject 
fear of the possessed, and the other of suggested 
evidences of possession. 

For about 200 years the whole of Europe was 
a vast charnel house owing to the countless 
numbers of the supposedly possessed who were 
put to death by many almost inconceivable 
forms of torture. The discovery of an anaes- 
thetic spot was sufficient evidence to condemn 
an individual, and very lucrative became the 
profession of detecting these unfortunates. The 
examiners went around searching for anaes- 
thetic areas in those who were suspected, and 
just as physicians seek for a certain kind of 
anaesthesia and by their examination alone 
create this product of suggestibility, so, too, 
did the witch hunters seek and create "evi- 
dences" of possession. Consequently, unnum- 
bered thousands of men, women, and children 
owed the loss of their lives to the effects of 
suggestion and to the ignorance of the age in 
which they lived. The history of such epi- 
demics, including our own small one of witch- 
craft, besides being of scientific interest scarce- 
ly can be other than conducive to reflections 
upon the injustice and barbarities which hys- 
terics have received. 

Even though epidemic hysteria be regarded 
merely as an acute and transitory form of the 
disease its symptoms, nevertheless, are just as 



Etiology 53 

severe as those observed in the most completely 
developed cases of endemic hysteria occurring 
upon a decided foundation of psychopathic 
heredity. Epileptiform convulsions, various 
rhythmical movements, hallucinations, delu- 
sions, and trance phenomena, are the most 
common of the severe manifestations which are 
prone to occur during epidemics. For instance, 
in describing the revivals among Southern ne- 
groes, Davenport writes: "At many of the 
'big quarterlies' and the 'protracted meetin's' 
which are held in the South, there are scenes of 
frenzy, of human passion, of collapse, of cata- 
lepsy, of foaming at the mouth, of convulsion, 
of total loss of inhibition, compared with the 
scorching heat of which the Indian ghost-dance 
seems at times only a pale moon." (Primitive 
Traits in Religious Revivals, 1906.) During the 
revivals among the whites of Kentucky, in 1800, 
among other manifestations such as visions and 
trances the same author describes the "bark- 
ing exercise:" "The votaries of this dignified 
rite gathered in groups, on all fours, like dogs, 
growling and snapping the teeth at the foot of 
a tree as the minister preached, — a practice 
which they designated as 'treeing the devil!' " 
Belief in the doctrines expounded during 
pathologic revivals is not essential to con- 
tagion ; in spite of the greatest efforts to with- 
stand them the manifestations might appear. 
Thus the Rev. Myron Eells spoke of the Indian 



54 Psychopathology of Hysteria 

Shaker religion: "It seems to be as catching, 
to use the expression of the Indians, as the 
measles. Many who at first ridiculed it and 
fought against it, and invoked the aid of the 
agent to stop it, were drawn into it after a 
little, and then they beeame its strongest up- 
holders." (Fourteenth Annual Report of the 
Bureau of Ethnology, Smithsonian Inst., p. 
748.) A typical instance is quoted by Sidis: 
"A gentleman and a lady of some note in the 
fashionable world were attracted to the camp 
meeting at Cone Ridge. They indulged in many 
contemptuous remarks on their way about the 
poor infatuated creatures who rolled over 
screaming in the mud, and promised jestingly 
to stand by and assist each other in case that 
either should be seized with the convulsions. 
They had not been long looking upon the 
strange scene before them, when the young 
woman lost her consciousness and fell to the 
ground. Her companion, forgetting his promise 
of protection, instantly forsook her and ran 
off at the top of his speed. But flight afforded 
him no safety. Before he had gone 200 yards 
he, too, fell down in convulsions." (Psychol- 
ogy of Suggestion, p. 352, 1899.) 

Epidemic hysteria reflects the ignorance of 
a people. In fact, it is the direct outcome of 
their state of unenlightenment and its mani- 
festations are the expression of their convic- 
tions. Indeed, one would be safe in affirming 



Etiology 55 

that among the intelligent of present, or of 
future ages, epidemics of demonophobia and 
the like could not be repeated. The history of 
recent times shows that the epidemics of de- 
moniac possession of the Middle Ages have been 
replaced by epidemics of religious revivals, of 
popular spiritualism, of financial bubbles, etc. 



CHAPTER III 

Disturbances of Sensory Perception 

IN the minds of the laity paralysis must be 
accompanied necessarily by numbness; 
paralysis implying that the affected mem- 
ber must "feel numb and dead." In 
most individuals this prevalent idea probably 
results from the temporary paralysis and 
numbness that most of us have experienced 
after having slept with the head pillowed on 
the arm. Hypnotic experiments conducted 
upon normal persons commonly demonstrate 
the existence of this erroneous conception; one 
that is based upon valid premises drawn from 
personal experience. If the suggestion is made to 
a hypnotized subject that one arm is paralyzed, 
then comparative tests of the sensibility of both 
arms will reveal almost invariably the presence 
of anaesthesia in the paralyzed one. This re- 
sult is obtained even when the experimenter 
has been most careful to eliminate the possi- 
bility of creating the anaesthesia by uninten- 
tional suggestion in his method of making the 
tests. As a consequence, then, of the concep- 
tion that numbness is a symptom of paralysis, 
a hysteric person who develops paralysis, either 
organic or functional, is apt to have an asso- 
ciated numbness, or anaesthesia, of the affected 
member. 

56 



Disturbances of Sensory Perception 57 

Among other similar cases Bernheim writes 
of a painter who, becoming the victim of 
saturnism, presented wrist-drop associated with 
analgesia of the dorsal aspect of the wrist and 
hand; the palmar surface and the fingers not 
being involved. The analgesia having been 
readily dispelled by means of suggestion, Bern- 
heim remarks that according to the patient's 
idea it was the dorsal surface of the hand and 
wrist which seemed to be the seat of trouble; 
it was there that his imagination localized the 
motor paralysis; it was there, also, that logi- 
cally he created a sensory paralysis. Being able 
to flex and to extend the fingers, these, in the 
patient's mind, were not paralyzed, and, there- 
fore, not anaesthetic. (Conception du Mot 
Hysterie, 1904, p. 11.) 

Independently of paralysis anaesthesia may 
be evolved in a number of ways. Thus, the 
transitory numbness following minor trauma- 
tism to sensory nerves may become fixed as a 
psychic anaesthesia through the instrumentality 
of autosuggestion. In the same manner the 
symptom may develop on the basis of a limb 
"going to sleep," or from the numbness that 
is noticed after an extremity has been held in 
a constrained position for a considerable length 
of time. 

It is not unusual for hemianaesthesia to ap- 
pear in patients who have a fear of apoplexy, 
due, perhaps, to the occurrence of this condi- 



58 Psychopathology of Hysteria 

tion in some relative or friend. Constantly ex- 
pecting to become hemiplegic, and believing 
that hemianagsthesia is a symptom, or even a 
forerunner, of the condition, patients may de- 
velop hysteric hemianaesthesia either with or 
without paralysis. 

Often it has been noticed, even in persons 
who were not considered to be subject to hys- 
teria, that a hand engaged in automatic writing 
became anaesthetic at the time. The explana- 
tion of this event is not difficult. In order that 
automatic writing can occur there must be 
coexistent dissociation of consciousness with 
elimination of the automatically functionating 
extremity from the field of consciousness. 
Not only are the motor functions dissociated 
but, commonly, the member as a whole is elided 
from consciousness with the result that sensory 
impressions originating in the part are not 
consciously perceived. 

When produced by any of these means, or 
by similar ones, anaesthesia may be said to be 
autogenous. Now, if a certain kind of anaes- 
thesia be considered a typical symptom of hys- 
teria, and if it is diligently sought by examin- 
ing physicians, both because of its interesting 
features and on account of its supposed diag- 
nostic import, then the condition intentionally 
or unintentionally may be created in the patient 
through the agency of the abnormally increased 
suggestibility that is characteristic of the dis- 



Disturbances of Sensory Perception 59 

ease. Thus, anaesthesia, and other symptoms, 
may be heterogenous. 

Parenthetically, the distinction between auto- 
suggestion and hetorosuggestion is only one of 
convenience in that these two terms super- 
ficially indicate, or appear to indicate, the 
source of the suggestion; the mechanism of 
production of symptoms by either form of sug- 
gestion being the same. When, by reason of 
a faulty technique, the examining physician 
unconsciously creates anaesthesia in a patient, 
or when the condition is deliberately suggested 
upon a hypnotized subject, it is produced only 
because the individual accepts and acts upon 
the implied or the evident suggestion that has 
been conveyed to him. The anaesthesias which 
have not originated from medical examinations 
usually follow some injury which has produced 
temporary numbness of the part, and the symp- 
tom thus suggested is fixed as a psychic anaes- 
thesia. In the ultimate analysis all effects of 
suggestion, whether apparently due to auto- 
suggestion or to heterosuggestion, are in reality 
examples of autosuggestion which has been 
provoked by an external stimulus, immediate 
or remote. 

That hysteric anaesthesia is almost invaria- 
ably the product of a faulty technique of ex- 
amination can easily be demonstrated clinically. 
If, for example, in ten consecutive cases whose 
tactile sensibility is being tested for the first 



60 Psychopathology of Hysteria 

time, the patient is told to close her eyes and 
immediately to say ' ' now ' ' when any part of her 
body is touched, anaesthesia probably will not 
be found in any, unless, perhaps, and this is 
unusual, autogenous anaesthesia had already 
existed. On the other hand, if, in a similar 
number of cases, the patient is told to close 
her eyes and say "now" if she is able to feel 
herself touched, anaesthesia will be discovered 
— created — somewhere in over a quarter of the 
cases, providing that the usual unnecessarily 
prolonged and careful examination be made. 

As commonly conducted the tests contain 
even a greater element of suggestion. Perhaps 
the physician states in advance that he intends 
to examine in order to ascertain if she has lost 
the feeling of any part of her body, or in some 
other way unintentionally conveys the impres- 
sion that anaesthesia is expected; that it is a 
symptom which she should possess. A state of 
expectant attention having been excited by 
these suggestive remarks the examiner pro- 
ceeds to stimulate various areas while asking 
if the patient feels "this," or if she can feel 
"that." Except direct hypnotic suggestion no 
better means could be employed intentionally 
to create anaesthesia. 

The more prolonged and thorough the exami- 
nation of sensibility the more frequently anaes- 
thesia will be found and, if the tests are re- 
peated during subsequent visits, it will be 



Disturbances of Sensory Perception 61 

fortunate, indeed, if one out of ten cases escapes 
the production of this "symptom." It is the 
avoidance, now, of such faulty methods of ex- 
amination that has caused heraianaesthesia to 
become so rare in the practice of many of the 
French neurologists when formerly it was a 
common symptom. 

These facts alone show that the experimental 
study of hysteria is largely the study of its 
symptomatic increased suggestibility, and that 
those who devote their time to the investigation 
of such manifestations as anaesthesia for the 
most part are really not dealing with essential 
symptoms of the disease but with the reactions 
of the patient to suggestion. 

As the confirmed hysteric is inclined to wan- 
der from one physician, or clinic, to another, 
the examinations of the first few physicians 
commonly are quite sufficient both to create 
and to render more or less permanent certain 
"stigmata." Those who have subsequently to 
deal with these old and repeatedly examined 
cases naturally do not cause by their own ex- 
aminations the production of these symptoms, 
and, no matter how careful their technique, 
anaesthesia and the like will probably be found 
for the reason that they had already existed. 

In the case of Lizzie B., a patient who had 
been examined by another physician without any 
sensory deficit having been noted, the conscious 
perception of tactile stimuli had become imper- 



62 Psychopathology of Hysteria 

feet and much delayed. After having been asked 
to state which side had been touched, the stimuli 
were referred to the corresponding point on the 
contralateral member — allocheiria. On repeat- 
ing these tests, after a short rest, she was unable 
consciously to perceive any of the stimuli. Thus, 
hysteric anaesthesia was created by the examina- 
tion. Now, by telling her that there really was 
nothing wrong with her sensibility, that she 
could feel, that she would signify her perception 
of each stimulus by saying "now" just as soon 
as she felt it, and each time that she would state 
exactly where she had been touched, both anaes- 
thesia and allocheiria were caused to disappear. 
These conditions did not return so long as she 
was under observation — over a year. 

As typical of the modern reaction from the 
extreme views of anaesthesia held by the older 
observers is Babinski's total disregard of the 
infrequent autogenous anaesthesia by his sweep- 
ing assertion that anaesthesia is always the result 
of suggestion during medical examinations con- 
ducted with a faulty technique. In support of 
his contention he states that during ten years he 
had not encountered hemianaesthesia among hy- 
steric patients who had not been previously ex- 
amined by others. In 1910 Bernheim, too, as- 
serted that since 1900 he has failed to discover 
hemianaesthesia in patients examined for the 
first time. In order to explain the absence of 
the condition in his service he states : ' ' To-day I 



Disturbances of Sensory Perception 63 

explore with the idea that it does not exist ; and 
this idea suffices to modify my technique of ex- 
amination, and to eliminate its suggestive char- 
acter." (Hypnotisme et Suggestion, Hysterie, 
Psychoneuroses, etc., 1910, p. 269.) 

Now there must be some way of reconciling 
such statements with the fact that other ob- 
servers found anaesthesia in from 75 to 95%, 
and hemianesthesia in 30 to 50% of their 
hysteric patients. The only plausible explana- 
tion for such conflicting results is that while 
formerly physicians created anaesthesias by rea- 
son of their faulty methods of examination, now, 
on the contrary, Bernheim, Babinski, and others 
have perfected their technique of examination 
to such a degree that no longer do they suggest 
the conditions upon the patient. 

But how account for the absence of autogen- 
ous anaesthesia and hemianaesthesia in the prac- 
tice of these physicians ? If it suffices to produce 
anaesthesia merely when the physician expects to 
find sensory deficits and examines his hysteric 
patients in accordance with his views, surely 
when one explores, as Bernheim does, with the 
idea that the condition does not exist, autogenous 
anaesthesia, if present, will disappear in conse- 
quence of the fact that his method of testing ex- 
presses his convictions. In the first instance the 
suggestive character of the examination is patho- 
genic ; in the second one it is therapeutic. That 
such an explanation is not improbable is indi- 



64 Fsychopathology of Hysteria 

cated by the fact that through the agency of in- 
tentional suggestion it is just as easy to cause 
anaesthesia to disappear as it is to create the con- 
dition. 

If anaesthesia were not usually of medical 
origin certainly the statements of Bernheim and 
Babinski would be remarkable in view of the 
fact that, until recently, this condition was one 
of the most frequent of the supposed symptoms 
of hysteria ; so frequent, in fact, that it was con- 
sidered stigmatic of the disease. 

It is such facts as these that lead one to ques- 
tion all theories of the disease, for no matter how 
well supported by facts they may seem to be, 
and no matter how general their acceptance, the 
history of the malady renders only too evident 
the effects of suggestion and of psychic conta- 
gion in the elaboration of innumerable hypo- 
theses which afterwards were proven to be erron- 
eous. 

Less radical are Janet's views concerning the 
significance of anaesthesia. To express the dif- 
ficulty in interpreting the psychologic character 
of hysteric anaesthesia he writes: "Now, your 
examination alone will suffice to cause a real 
anaesthesia to disappear; now — and this is more 
serious — your manner of interrogating will 
create outright an anaesthesia that did not exist. 
The study of the stigmata is made on no patients 
so well as on old ones; real pillars of the 
hospital, who have already been examined 



Disturbances of Sensory Perception 65 

thousands of times. When you have to deal with 
new patients, who have not yet been touched, 
you recognize with astonishment that anaesthesia 
is rarer, less important than Charcot said. On 
this point I apologize myself, and acknowledge 
that, under the influence of la Salpetriere, I 
formerly attributed more importance to anaesthe- 
sia than I would do now." (Major Symptoms 
of Hysteria 1907, p. 274.) 

In an earlier work we find the following sig- 
nificant statement pertaining to hysteria in the 
young : ' ' The patients, in the beginning, have no 
anaesthesia; this has been observed by all au- 
thors." (Mental State of Hystericals, 1892, Cor- 
son trans. 1901, p. 47.) Why do not young 
hysterics present anaesthesia? Being young 
these patients have not yet been examined by 
numerous physicians and thus heterogenous 
anaesthesia is less apt to have been created, and 
because of their age they are not apt to possess 
knowledge of such a condition as anaesthesia so 
that it is not liable to develop as an autogenous 
symptom. 

In connection with anaesthesia it was form- 
erly noticed with astonishment that what should 
be a distressing symptom almost never was 
made the subject of complaint. Or, that the 
majority of patients were not aware of their 
sensory deficit until this was revealed by an 
examination. The patient might exclaim: 
"Why, I never knew that I couldn't feel in 



66 Psychopathology of Hysteria 

that arm!" The majority, however, expressed 
neither surprise nor concern when the physi- 
cian spoke of anaesthesia which he had found 
and whose existence previously had been un- 
known. 

By means of the argument that hysteric 
anaesthesia is only subjective and that as such 
the patient really perceives tactile and other 
stimuli but that the perceptions are not syn- 
thetized with consciousness, exception might 
be taken to the view that this symptom is com- 
monly produced only by suggestive examina- 
tions. Though quite true as an explanation of 
the inocuous nature of existing anaesthesia 
logically it does not seem legitimate to con- 
clude that all anaesthesias antedate the exami- 
nation during which they are discovered both 
by physician and by patient. Practically, the 
weight of evidence is overwhelmingly against 
such reasoning. 

In their conceptions of diseases of different 
parts of the body laymen think in popular 
terms of arms, legs, halves of the body, etc., 
and not in scientific ones of peripheral sensory 
distribution. Naturally, then, hysteric anaes- 
thesia, being entirely psychic in origin, does 
not conform with the anatomical peculiarities 
of sensory distribution. The one conceivable 
exception to this rule is the possible occurrence 
of psychogenetic anaesthesia limited to the dis- 
tribution of a sensory nerve as a result of the 



Disturbances of Sensory Perception 67 

fixation of transitory numbness provoked by- 
slight traumatism to that nerve. The atten- 
tion of the patient having been directed to the 
symptom and to that particular distribution 
unconscious autosuggestion amplifies and fixes 
the primarily organic symptom. 

In view of its anatomical inconsistency any 
anaesthesia is suggestive of hysteria when it is 
limited precisely to one lateral half of the body, 
when it surrounds an arm or a leg like a glove, 
a coat sleeve, a stocking, etc., or when it occurs in 
irregular disseminated patches. Total hysteric 
anaesthesia is most exceptional. 

The borders of organic anaesthesia are fixed, 
or varying but gradually, and they are not well 
defined because of the overlapping that exists 
in the distribution of the various nerves. Those 
of hysteria, however, are sharply delineated 
and varying much from one examination to 
another, and even during the same examination. 
In fact, their borders can be determined at 
will according to the use of suggestion by the 
examiner. 

The following instance, mentioned by Prince, 
shows how readily the hysteric is influenced by 
the conceptions of her physician, and, therefore, 
how one is apt to discover, or unintentionally 
to create, whatever one expects to find : "In one 
instance the examining physician, thinking the 
limiting line should be two inches from the 
median line on the anaesthetic side, demonstrated 



68 Psychopath ology of Hysteria 

this boundary, but when erroneously told it 
should be on the opposite side, corrected, as he 
thought, his faulty observation and demon- 
strated the line in the new situation." (Amer. 
System of Pract. Med., p. 643.) 

Hysteric anaesthesia does not occasion loss of 
the reflexes except, perhaps, „ those of the skin, 
and, during sleep, stimulation of an anaesthetic 
limb not only may cause its withdrawal but even 
verbal remonstrances may be provoked. Also, it 
has been noticed that hysteric anaesthesia may 
disappear during the exhilaration caused by 
drugs. Finally, there need not be any impair- 
ment in the use of the affected member ; with her 
eyes closed the patient being able to write, for in- 
stance, even though unable consciously to feel 
the pencil she grasps. 

Quantitatively, hysteric anaesthesia may be 
complete or incomplete; conscious perception 
either being absent or only impaired. Not only 
the skin but the mucous membranes, or both, may 
be involved. Qualitatively, any one or all of 
the various kinds of sensory perception are 
capable of being the subject of disturbances sim- 
ilar to those of tactual perception. In hysteria, 
as well as during hypnosis in a normal person, 
it has been noticed that small wounds in an an- 
aesthetic region are not apt to produce haem- 
orrhage or, in fact, even that haemorrhage may 
not appear at all, and that perspiration may be 
lessened in the same region. 



Disturbances of Sensory Perception 69 

Let us examine some patients and, by means 
of suitable experiments, demonstrate the pecul- 
iarity of hysteric anaesthesia and attempt to de- 
termine its nature. The most easy and convinc- 
ing experiments are accomplished with the aid 
of hypnosis. Numerous ones have been devised 
and with a little ingenuity anyone can contrive 
others suitable for the case at hand. Sometimes 
one will fail while, in the same patient, the appli- 
cation of another is attended with success. If 
differentiation from organic anaesthesia depends 
upon such tests alone, one successful result indi- 
cates that this one symptom, at least, is hysteric 
in origin no matter how many other experiments 
were failures. 

Suppose we blindfold a patient who presents 
an old, well organized, and complete anaesthesia 
and then lightly touch the anaesthetic region 
a certain number of times. Upon being ques- 
tioned the patient asserts positively that she 
has not felt anything. Now we hypnotize her 
and suggest that she tells us how many tactual 
impressions were perceived. Without hesita- 
tion she states the correct number. If, in a 
manner that is not too obvious, the experi- 
menter suggests to the patient that she will in- 
form him of the number of the impressions which 
she perceived in many cases a successful result 
will be secured without resorting to hypnosis. 

In a patient with long continued hemianaes- 
thesia occurring in association with organic 



70 Psychopathology of Hysteria 

hemiplegia all forms of sensibility were lost on 
the affected side of the body; In consideration 
of the history of the patient, together with the 
findings of a hurried first examination, it was 
thought that the sensory loss was one of the 
consequences of a cerebral haemorrhage. Im- 
mediately afterwards he was carefully ex- 
amined before a body of students. Even in 
this patient, one familiar with many clinics 
and with neurologic examinations, it was pos- 
sible, during this second examination, to carry 
out successfully the above procedures without 
resorting to hypnosis. Disregarding other facts 
and excluding a number of peculiarities which 
were inconsistent with organic hemianesthesia, 
the results of these tests alone would have been 
sufficient to prove that the hemianagsthesia, at 
least, was hysteric in nature. The sensory de- 
ficit was too general and too absolute; he ap- 
peared to exhibit absolute loss of every form 
of sensibility that was tested. Thus he asserted 
that he could not feel tactual, painful and 
thermal impressions and that osseous sensibility 
to the tuning fork was absent. Even though 
several pounds of pressure was exerted, suffi- 
cient to push his leg along the floor, he said 
that he felt nothing. When the affected limbs 
were placed in various positions and he was 
told to retain these passively assumed attitudes 
he did so without other support than his own 
efforts. He was unable, however, to duplicate 



Disturbances of Sensory Perception 71 

these postures with the members of the other 
side because as he asserted, he did not know 
where the paralyzed ones were located. Be- 
sides the experiments that demonstrated posi- 
tively his perception of various kinds of stimuli 
the anomalous character of his sensory losses 
was sufficient to reveal their psychic nature. 

During examination of tactile sensibility it 
is frequently noticed that the patient starts 
slightly whenever the anaesthetic region is 
stimulated, yet consciously she does not per- 
ceive the impressions. 

By training the patient to carry out some 
simple act each time a normal area of the skin 
is stimulated it is often possible to obtain the 
same response when an anaesthetic region is 
stimulated in the same manner. Janet has suc- 
ceeded in causing the patient to say "yes" 
when a normal area of the skin was touched, 
the patient's eyes being shielded, and "no" 
when an anaesthetic area likewise was stimu- 
lated. This curious result was obtained by tell- 
ing the patient in advance that she was to an- 
swer affirmatively when the tactile impression 
was perceived, and negatively when it was not 
felt. After these instructions the physician 
must proceed rapidly with his tests in order 
not to give the patient time to think about the 
inconsistency of the replies. Naturally, too, if 
she is intelligent enough to remark this incon- 
sistency not only will the procedure fail but 



72 PsycJiopathology of Hysteria 

the physician exposes himself to censure for 
implying that she was malingering. 

The same author speaks of a patient with 
hysteric total anaesthesia upon whom elec- 
tricity was being employed for therapeutic 
purposes. One day it was noticed that on each 
application of the electrode strong muscular 
contractions appeared as usual, although by 
accident the electrodes had been disconnected, 
and, furthermore, the patient could not see 
when the applications were made. Here, then, 
through unconscious autosuggestion, there oc- 
curred motor reaction to a supposed applica- 
tion of electricity even though by reason of 
her anaesthesia the patient consciously could 
not perceive the application of the electrode. 
(Janet: op. eit., p. 27.) 

In order to demonstrate the doubling of con- 
sciousness in hysteria Alfred Binet adduced 
some interesting experiments upon patients 
with complete anaesthesia of an upper extrem- 
ity. He pricks the hand a certain number of 
times and then asks the patient what number 
comes into his mind. Often the patient gives 
the same number as that of the pricks he 
was unable to feel. To vary the experiment 
some object may be placed in the anaesthetic 
hand and then the patient asked to name the 
thing of which he is thinking. Having screened 
the hand Binet passively flexes and extends- 
one of the fingers a number of times. Pre- 



Disturbances of Sensory Perception 73 

quently he finds that the movements automati- 
cally continue a few times after he ceases im- 
parting the passive motion. In order to continue 
the actions of flexion and extension the patient 
must have perceived the sensory impressions — 
muscular and articular — produced by the pas- 
sive movements. Subconscious perception and 
recognition accounts, too, for the fingers grasp- 
ing in the correct manner such objects as scis- 
sors or a pen which are placed in the anaes- 
thetic hand. By means of guiding the screened 
movements of the pen the same author causes 
the hand to write a familiar name. In doing 
so the name intentionally is misspelled. Now, 
having started the hand to rewrite the name 
the writing is automatically completed, but 
often the mistake is corrected. This experi- 
ment shows that not only did there occur sub- 
conscious perception of the primarily passive 
movements but that some kind of intelligence 
which was apart from the consciousness of the 
patient recognized and corrected a mistake in 
orthography. Finally, becoming accustomed to 
automatic writing the patient writes a word 
which has been traced upon the back of his 
anaesthetic hand. (On Double Consciousness, 
1905.) 

By proving that, in spite of what appears to 
be complete anaesthesia, patients do perceive im- 
pressions arising in the affected region the term 
anaesthesia — without feeling — is shown to be a 



74 Psychopathology of Hysteria 

misnomer. Then, are all patients with hysteric 
anaesthesia nothing but malingerers? Success- 
fully to simulate a condition with such peculiar 
qualities would necessitate that the individual be 
exceedingly clever and stoical enough to with- 
stand pain without a murmur. However, no 
person who is simulating with a definite object in 
view would expose his malingering by reacting to 
experiments in the manner which has just been 
described. 

Might not a woman simulate anaesthesia solely 
in order to provoke attention? If anyone should 
simulate the symptom with no other apparent 
object than to excite interest the condition could 
not be considered malingering in the sense that 
this term is commonly employed, but the rea- 
son for the simulation alone would be indicative 
of one of the mental peculiarities of hysteria. 

It is safe to look upon hysteria as the only 
condition — except insanity — in which an adult 
might simulate for the purpose of arousing sym- 
pathy. But, simulation of anaesthesia by a 
hysteric is rare, and enough has been written al- 
ready to show that hysteric disturbances of 
sensory perception are symptoms over which the 
patient has not any control, originating, as they 
do, in dissociation of consciousness. 

The curious qualities of hysteric anaesthesia 
can be interpreted in only one way. It is only 
a psychologic explanation which is adequately 
capable of accounting for the fact that a patient 



Disturbances of Sensory Perception 75 

is unaware of a perception whose existence can 
be demonstrated. Hysteric anaesthesia, and 
other similar disturbances of perception, can 
be made intelligible by assuming that while sen- 
sory impressions really are perceived there is 
lack of synthesis of the percepts with conscious- 
ness. In other words, there is deficiency of per- 
sonal perception, or, less technically to express 
the condition, hysteric anaesthesia, as indicated 
by Lasegue in 1864, is but a result of patholo- 
gic exaggeration of normal absent-mindedness, 
personal examples of which each of us can 
readily recall. It is, then, only the exaggeration 
of the normal peculiarity of the human mind 
which permits one to search for the hat which 
is upon his head, or which is accountable for the 
fact that soldiers who have been wounded often 
continue to fight without feeling any pain, and, 
in fact, even ignorant of the wounds which they 
have sustained. 

Hysteric anaesthesia might be compared, also, 
with the field of attention in the act of vision. 
One whose attention is concentrated on an object 
in any portion of the visual field may not con- 
sciously perceive objects in any other portion of 
the field, yet experimentally it has been demon- 
strated that under these conditions there has 
actually occurred subconscious perception of 
visual impressions in the field peripheral to the 
fixation point of attention. 



76 Psychopathology of Hysteria 

According to Janet, hysteria is characterized 
by retraction of the field of consciousness with 
the consequence that the patient is unable to at- 
tend to the many impressions which are con- 
stantly being conveyed to the brain from dif- 
ferent parts of the body. Certain perceptions, 
therefore, are ignored, and this primarily volun- 
tary suppression of perceptions, becoming ha- 
bitual, results in the production of anaesthesia, 
amaurosis, etc. 

Freud looks upon anaesthesia and other symp- 
toms as symbolic representations of former ex- 
periences which have been forgotten — suppressed 
— because of their unpleasant nature. This ex- 
planation of the absence of personal perception 
is not, however, universally applicable. It does 
not explain, for instance, why anaesthesia may 
appear after traumatism of which the patient has 
a most vivid recollection. It is eminently practi- 
cable in those cases in which the disease has de- 
veloped after more obvious psychic insults whose 
memories really have been suppressed from 
consciousness. 

Although hysteric anaesthesia does not usually 
cause any disturbance of the motor functions of 
the affected part there may occur occasionally, 
in a profoundly anaesthetic member, an asso- 
ciated motor disability that is present only when 
the patient's eyes are closed, or when they are 
directed away from the part. This pseudo- 
paralysis, known as Lasegue's syndrome, is appar- 



Disturbances of Sensory Perception 77 

«nt only during attempts to perform consciously 
some movement ; automatic and lower reflex acts 
not being impaired. When a part is the seat of 
total hysteric anaesthesia it is non-existent to the 
patient unless she can see it, or feel it with some 
-other member, and this alone is quite sufficient 
to account for the condition. Such an explana- 
tion is supported by the fact that these patients 
are able, with the assistance of visual imagina- 
tion or of tactile impressions, to carry out a 
movement, and, furthermore, subconscious move- 
ments are not affected. Unless originating as a 
psychologic artefact — a product of too careful 
study or of unconscious suggestion during 
medical examinations — it would seem that the 
development of Lasegue's syndrome is, to say 
the least, most improbable. 

The mental processes of sensory perception 
have been divided by Ernest Jones into two 
groups; the first of which comprises those pro- 
cesses dependent upon esthesic impulses, and 
the second group, designated auto-somatognos- 
tic, embraces the memory feelings of different 
parts of the body. It is by reason of the normal 
activity of memories of feelings that have been 
experienced in the past that enables one to 
recognize not only that a sensory percept results 
from a stimulus applied to a certain part of 
the body, but also to know which side had been 
stimulated. And it is by association with these 
memories that a sensory percept is experienced 



78 Psychopathology of Hysteria 

with the warmth that implies personal percep- 
tion. Now, according to the same author, if 
the esthesic sensibilities — tactile, pain, eoenes- 
thetic, etc. — return first, during recovery from 
hysteric anaesthesia, there results impairment 
of personal perception so that the patient de- 
scribes a tactual perception as having been 
induced by a sensory impression in a part that 
does not belong to his body, or the perception 
is referred to a corresponding point on the con- 
tralateral member whose sensibility is normal. 
As an instance of the former Jones writes of a 
patient who said: "You are touching the 
back of some fore-finger with a blunt pin; it 
isn't my finger and I have no idea where it is, 
but it causes an intensely disagreeable shudder 
to run all up one side of me. ' ' 

Dyschiria, or difficulty in naming the side of 
the body from which a sensory impression has 
been perceived, is due to loss of the" ' chirognos- 
tic" sense — the feeling of sidedness. Sensory 
dyschiria is divided by the same author into 
achiria when the patient cannot recognize which 
side of the body has been stimulated, though the 
sensory impression was perceived, allochiria when 
the stimulus is referred to a corresponding point 
on the opposite side of the body, and synchiria 
when a stimulus simultaneously arouses the 
feeling of a sensation at corresponding points 
of each side of the body. (The Precise Diag- 
nostic Value of Allochiria, Brain, 1907, p. 



Disturbances of Sensory Perception 79 

490. The Significance of Phrictopathic Sen- 
sation, Jour, of Nerv. and Ment. Dis., 1908, p. 
427. The Dyschiric Syndrome, Jour, of Abn. 
Psych., vol. 4, p. 311, etc.) 

Like Lasegue's syndrome, it is probable that 
most of the instances of dyschiria were the pro- 
duct of examinations during which this condi- 
tion was sought. When by reason of the sug- 
gestive technique of the examination patients 
are permitted to grasp the idea that it is pos- 
sible for a stimulus to be incorrectly localized 
allochiria and other defects in tactual orienta- 
tion not infrequently are discovered. Accord- 
ing to the usual technique the patient's hand, 
for instance, is stimulated and then she is asked 
first if she felt anything, then which hand was 
touched. I venture to state that these defects 
will never be found if, instead of such a sug- 
gestive technique, the physician casually tells 
the patient that after closing her eyes she will 
perform a certain act when her right hand is 
touched, and a different one when the left 
hand is stimulated. 

In common with other manifestations anaes- 
thesia may be transferred from side to side, 
modified, and even caused to disappear by 
means of the local application of metals, mag- 
nets, or any kind of apparatus, provided only 
that the patient can be induced to anticipate 
any of these results. These phenomena, the 
consequence of expectant attention on the part 



80 Psychopathology of Hysteria 

of the patient and of suggestion on that of 
the physician, besides being additional evidence 
of the psychic nature of symptoms of hysteria, 
are mentioned in order further to indicate how 
readily one can misinterpret these manifesta- 
tions, and how natural it is to ascribe curative 
virtues to drugs and to other therapeutic means 
whose beneficial action is due entirely to sug- 
gestion and to expectant attention. 

On account of ignoring the effects of sugges- 
tion many papers and books concerning the 
curious and remarkable therapeutic effects of 
local application of metals, magnets, etc., were 
written during the last century. In fact, 
metallo-therapy and magneto-therapy were 
practiced as late as 1880 by many famous 
physicians and at many hospitals; including la 
Salpetriere. Even some of the recent text- 
books contain descriptions of the peculiar 
effects of applications of metals or of magnets 
to anaesthetic or paralyzed members, without 
however, suggestion being recognized as the 
true cause of these modifications. It is the 
same principle that caused the vogue of Per- 
kin's metallic tractors, electric belts, valerian, 
asafoetida, and the like. It is curious that 
while many physicians are quite willing to 
grant that suggestion is capable of producing 
and of modifying symptoms of hysteria yet 
they do not recognize the pathogenic effects of 
their own suggestive examinations, and they 



Disturbances of Sensory Perception 81 

accept with avidity new therapeutic agents 
whose supposed virtues, in the treatment of 
the disease, are dependent entirely upon sug- 
gestion. 

In case hysteric anaesthesia has not existed 
for a long time, and provided that it has not 
been made the subject of much experimenta- 
tion, and that sensibility is not examined 
repeatedly, it is usually an easy matter to cause 
the condition to disappear. Otherwise, it may 
continue indefinitely as shown by the old 
Salpetriere patients; ones that have served as 
clinical material for a succession of authors. 
Before proceeding, it is advisable perhaps to 
state that, excluding exceptional cases in which 
the diagnosis is obscure, the physician is not 
justified in creating the "stigmata;" condi- 
tions which may persist indefinitely unless 
removed promptly by suggestion. Enough has 
been written already to point out that the only 
diagnostic significance they possess is the in- 
creased suggestibility which they imply. 

As already mentioned, hysteric disturbances 
of sensibility are not confined to the tactile 
sense. Besides absence of conscious percep- 
tion of tactile impressions there may occur 
similar perceptual derangements involving the 
pain sense — analgesia — , the temperature sense 
■ — thermo-anaesthesia — , the pressure, muscle, 
vibratory, and electrical senses. Being of 
great importance, "anaesthesia" of the special 



82 Psychopathology of Hysteria 

senses will receive consideration in a separate 
chapter. 

Excepting loss of the muscle sense — a condi- 
tion whose existence is incapable of being con- 
ceived by most patients — a part which is the 
seat of hysteric anaesthesia is usually affected 
also with loss of the pain, temperature, and 
perhaps even other, senses. Necessarily this 
must be true, for patients do not possess knowl- 
edge of the anatomic and physiologic differen- 
tiation of sensibility, and, consequently, a part 
that is numb must be numb to all kinds of 
stimuli. 

Earely, involvement of the muscle sense may 
occur independently in cases of profound 
anaesthesia, but it may be found more fre- 
quently if the condition is sought, for then the 
attention of the patient is directed to the pos- 
sibility of the occurrence of this manifestation. 
As compared with what should be observed in 
ease of organic loss of muscle sense the hysteric 
variety presents some characteristics which, to 
say the least, are peculiar. Thus, the hysteric 
is able to maintain the position in which a limb 
has been passively placed while her eyes were 
closed, yet, as in two patients I have observed, 
she asserts that she does not even know where 
her limb is located. This would be utterly im- 
possible if the disturbance were organic and 
advanced to such a degree. Then, too, the 
hysteric may be able, without the assistance of 



Disturbances of Sensory Perception 83 

vision, to move the affected extremity without 
any ataxia becoming apparent, even though she 
is unable to duplicate the position in which the 
contralateral and normal member has been 
placed. Other patients who, during an exami- 
nation, present decided hysteric incoordination 
of the lower extremities, afterwards walk 
around without exhibiting ataxia. 

While examining a hysteric there not infre- 
quently develops a kind of static ataxia, but 
even if this be sufficient to cause her to fall, it 
does not seem to occasion any inconvenience, 
and almost invariably it can be caused to dis- 
appear if the physician impresses the patient 
with positive assurances of her ability success- 
fully to stand with the eyes closed. It will be 
noticed, too, that the patients who present this 
inocuous form of ataxia are often the ones who 
complain of vertigo. This is significant be- 
cause the vertigo serves as a basis from which, 
by autosuggestion, static ataxia is developed. 

The conclusion to be drawn from study of the 
various kinds of disturbances of sensory percep- 
tion that have been described is that one can not 
be too careful in testing for the purpose of 
eliminating possible organic disease, because, if 
the patient is a hysteric, the very conditions that 
are sought will be created solely by reason of 
unconscious suggestion, unless the technique of 
examination is almost perfect in its freedom 
from pathogenic suggestion. 



84 Psychopathology of Hysteria 

Formerly, the discovery of hyperesthetic 
areas in the inframammary and ovarian regions 
was supposed to possess considerable diagnostic 
significance. Clinical experience shows, how- 
ever, that if pressure is made in any part of the 
body while asking the patient if pain is pro- 
duced, areas of hyperesthesia can be cre- 
ated without further suggestion in almost 
all cases of hysteria, and wherever one desires. 
On the other hand, this symptom will almost 
never be found if the regions supposed to be the 
elective seat of hyperesthesia be pressed upon 
while the patient's attention is directed else- 
where, or if the pressure be made without hav- 
ing caused the patient to believe that pain or 
any other unpleasant sensation is expected. 

Inasmuch as it was customary, and for obvious 
reasons, to regard the ovarian and the inframam- 
mary regions as the ones in which hyperesthesia 
commonly existed, these were the only ones which 
ordinarily were subjected to examination. Con- 
sequently, hyperesthesia in these regions was 
supposed to be valuable evidence in favor of the 
diagnosis hysteria. Now, we can interpret this 
"stigma" almost invariably to be the conse- 
quence of the suggestive manner in which it is 
sought. 

When occurring independently of examina- 
tions, quite commonly hyperesthesia results as 
the peripheral projection of hallucinatory pain 
arising from a fixed belief that has been en- 



Disturbances of Sensory Perception 85 

gendered — suggested — by some former accident 
or unpleasant experience. In some of these 
cases the hyperesthesia or pain has been caused 
to continue long after the painful effects of the 
trauma, or of the disease process from which it 
originated, should have disappeared; the con- 
tinuation being due to fixation of the symptom 
by expectant attention. Following an operation 
for appendicitis, for instance, the patient may 
continue to complain of pain or of hyperesthe- 
sia around McBurney's point. If pressure be 
exerted in this region the perception, by asso- 
ciation of ideas with the memory complex con- 
cerning the former appendicitis and the op- 
eration, arouses a mental representation so vivid 
as to cause the hallucination of pain. That the 
symptom is not due to adhesions or to some other 
cause of actual pain can be demonstrated by 
causing, through psychotherapeutic means, com- 
plete and permanent removal of the pain. 

Synesthesia is the name applied to that phe- 
nomenon characterized by mental representation 
of a perception of one kind of sensation in conse- 
quence of a stimulus to a totally different sen- 
sory system. In the subdivision of synesthesia 
known as audition coloree the hearing of a cer- 
tain name, or sound, arouses a fixed color rep- 
resentation. The various kinds of synesthesia 
are due to associations of ideas which were 
usually formed in infancy. Suppose, however, 
by reason of the same process — association of 



86 Psychopathology of Hysteria 

ideas — the sight of a knife or the word "op- 
eration" should provoke hallucinatory pain be- 
cause these stimuli "touch" the repressed com- 
plex of a surgical operation : then this analogue 
of an instance of normal synesthesia is patholo- 
gic because it is not compatible with the best in- 
terests of the individual. 

In the absence of an organic cause for the 
symptom, hysteric pain may be regarded as the 
hallucinatory expression of a subconscious mem- 
ory of pain. Prince compares hysteric pain with 
the power of mental representation possessed by 
good visualizers and auditives, who revive with 
the intensity of a hallucination the visual or au- 
ditory memories of past experiences. He consid- 
ers hysteric pain to be a quasi-hallucination due 
to revival of memory images of a former and 
actual pain. (Amer. Syst. of Pract. Med., p. 
628.) 

Hyperesthesia and pain may occur also in 
any hysteric patient who has a variety of symp- 
toms which imply, to her, a disease that ordi- 
narily is accompanied with pain or tender- 
ness. If the pain is located in the breast and 
is associated with hysteric oedema it is pos- 
sible to mistake the condition for tumor of the 
breast. Ovarian disease, coxalgia, and other 
organic diseases may be mimicked in the same 
manner. Hysteric pseudo-migrane is very com- 
mon; perhaps more than half of the so-called 
cases of migrane in women really are hysteric 



Disturbances of Sensory Perception 87 

in origin, and, therefore, the condition has no 
other relation to true migraine than its super- 
ficial resemblance to this disease. 

By reason of the psychic nature of hysteria 
there is not any structure in which organic pain 
can arise that is not capable also of being the 
seat of externalized pain of psychic origin. At 
all events there should not be any difficulty in 
distinguishing between organic pains and those 
due to hysteria. 

The hysteric often smiles pleasantly while 
describing the severe pain with which she is 
afflicted and though her suffering, judging from 
her description, is so intense that it should pros- 
trate her, yet it does not seem to cause any 
real distress. While conversing with the pa- 
tient one frequently gains the impression that 
the emotional and physical reactions are exag- 
gerated, and, upon resorting to a physical ex- 
amination, careful search fails to reveal any 
physical cause for pain, or one is found which 
is insignificant as compared with the amount of 
pain of which the patient complains. 

Pressure upon the alleged painful region not 
only may provoke an exaggerated expression 
of distress but it may precipitate some one of 
the innumerable kinds of hysteric crisis. Dur- 
ing distraction of the patient's attention, how- 
ever, the same procedure may be repeated with- 
out causing any evidence of pain whatever. 
The so-called hysterogenic zones can be de- 



88 Psychopatkology of Hysteria 

scribed more appropriately in connection with, 
the attacks of hysteria. 

Painful organic conditions of the chest and 
abdomen are productive of a characteristic type 
of disturbance of respiration; the rate usually 
being increased, and inspiration being superfi- 
cial and repressed. Hysteric pain referred to 
the same regions may be accompanied by in- 
creased frequency of respiration, but, instead 
of being shallow and interrupted in type, in- 
spiration is free and enormously increased in 
depth ; especially when pressure is applied over 
the seat of pain. In case of abdominal pain a 
valuable differential sign is afforded by the 
fact that if we press upon that part of the abdo- 
men which the hysteric asserts is painful, we 
notice the absence of the protective rigidity 
that is aroused by painful organic abdominal 
disease. 



CHAPTER IV 

The Disturbances of Sensory Perception — The 
Special Senses 

VISUAL Perception. Amaurosis, an 
unusual condition, though much 
less uncommon than was formerly- 
supposed to be the case, may be 
unilateral or bilateral, paroxysmal or con- 
stant, complete or incomplete — amblyopia — , and 
it may persist for many years or appear only 
as a transitory manifestation. Usually this 
special type of psychic anaesthesia develops in 
females, and the unilateral form of visual 
deficit is decidedly more common than bilateral 
amaurosis. Amblyopias are encountered much 
more frequently than amaurosis, and, like anaes- 
thesia, they may be either autogenous or the 
result of suggestion during examination of the 
patient's vision. 

Not a few of the reported cases of monocular 
amaurosis and amblyopia have occurred in 
association with homolateral hemiansesthesia 
and similar unilateral sensory derangements. 
The reason for this is apparent when one stops 
to consider that, in the minds of the laity, hemi- 
anaesthesia should include all of the senses of 
one lateral half of the body. 

When amaurosis occurs independently of hemi- 
anaesthesia the cornea and the skin immediately 

89 



90 Psychopathology of Hysteria 

surrounding the eye may be the seat of anaes- 
thesia. This may be explained in the same 
manner that we account for the anomalous bor- 
ders of ordinary anaesthesia. Just as the layman 
thinks in popular terms of arms, forearms, and 
legs, so does he think of the eye as including 
vision, the eye ball, the eyelids, and adjacent 
structures ; the popular use of such expressions as 
1 ' closing of the eyes" being somewhat indica- 
tive of this conception. Accordingly, in asso- 
ciation with psychic amaurosis what is more 
natural than the occurrence of subjective 
anaesthesia of the cornea, and eye lids? 

The exciting cause, particularly of monocu- 
lar amaurosis, often is found to be some 
trauma, rarely other than trivial, which the 
patient believed capable of producing blind- 
ness. For instance, in one of Gradle's cases 
hysteric monocular amaurosis followed an in- 
jury adjacent to, but not involving, the af- 
fected eye. (Jour, of the A. M. A., April 24, 
1909, p. 1308.) 

Like the production of other symptoms of 
hysteria it would appear that anything which 
merely concentrates the patient's attention 
upon the visual function is sufficiently sugges- 
tive to result in amaurosis or amblyopia. In 
two of my own cases amaurosis was evidently 
caused by procedures which had induced con- 
centration of the patient's attention upon 
vision. 



The Special Senses 91 

Miss M., aet. 23, presented typical major 
symptoms of hysteria. October 12, 1908, a 
drop of tuberculin solution was instilled into 
her right eye, and, to control the test, a drop 
of saline solution was placed in the left one. 
The great importance, to her, of the results of 
the Wolff-Eissner test led Miss M. frequently 
to examine her eyes ; in fact, there was aroused 
a constant state of expectant attention cen- 
tered upon her eyes and upon vision. The 
next day, though both eyes appeared to be 
normal, the patient complained of a feeling of 
irritation in the left one, and of homolateral 
impairment of vision. She was told, then, that 
the tuberculin had been instilled only into 
the right eye. Complete monocular psychic 
amaurosis, affecting vision with the right eye, 
was present when she awakened the following 
morning. Having had explained to her the 
nature of the blindness, and after positive as- 
surances that her vision would become normal 
in the course of a few days, the symptom was 
caused to disappear promptly without necessi- 
tating recourse to other procedures. 

In the case of Mabel A., a major hysteric, 
aet. 12, attacks of complete bilateral psychic 
amaurosis developed 22 days after perimetric 
examination and without any other probable 
cause being ascertainable. The prolonged and 
repeated examination with the perimeter, a 
quite sufficient cause for the production of the 



92 Psychopathology of Hysteria 

symptom, so concentrated the attention of the 
patient upon her visual function that, follow- 
ing a not uncommonly extended period of 
meditation, or of autosuggestion, amaurosis ap- 
peared. The attacks of amaurosis, each of 
which lasted several hours, were caused to dis- 
appear without difficulty by means of sugges- 
tion during the hypnotic state. 

The shock of being told by another physi- 
cian that her fundi showed evidences either of 
urgemia or of tuberculosis ( !) was sufficient 
in one patient to provoke bilateral amblyopia 
of high degree. After the elimination of pos- 
sible organic causes for the reduction in visual 
acuity psychotherapy was effectual in causing 
speedy return of vision to normal, and, it is 
needless to say, ophthalmologic examination 
resulted in negative findings. 

Another instance of an emotional cause is 
worthy of mention. A young lady was much 
agitated in anticipation of singing a solo in 
church. When the time arrived her vision be- 
came indistinct and the congregation seemed 
to disappear from view. These symptoms 
might appear in anyone and without further 
difficulty being experienced. In the case of 
actors with stage fright often the audience ap- 
pears to be blotted out, but this systematized 
amaurosis is only a temporary manifestation of 
a reaction of defense. As stage fright is 
primarily due to fear of the audience suppres- 



The Special Senses 93 

sion of the visual image of this body must be a 
conservative process. At all events, the young 
lady was subject to hysteria, and, consequently, 
the temporary emotional blurring of vision be- 
came elaborated into complete bilateral 
amaurosis. It was necessary to lead her home, 
and the symptom persisted for three days, 
when spontaneous recovery of vision occurred. 
Following this experience any decided excite- 
ment was sufficient to provoke a similar at- 
tack. 

Recurrence of hysteric accidents is common. 
It seems that any emotional disturbance tends 
to cause repetition of former pathologic reac- 
tions providing that another kind of reaction 
is not casually suggested upon the patient. 
Moreover, transitory attacks of amaurosis are 
quite common; it is only the more permanent 
ones which are unusual. 

As all the possible accidents of hysteria are 
potential in a given case and as each requires 
only an adequate exciting cause to render it 
actual, so in these four cases the diagnostic 
tests and the emotional disturbances were quite 
sufficient to determine the genesis of amaurosis. 
Naturally, a factor which is capable of acting 
as the exciting cause of a symptom in one 
hysteric individual is of negligible etiologic 
importance in others ; the harmlessness of the 
factor or the induction of pathologic conse- 
quences depending entirely upon the personal 
equation. 



94 Psychopathology of Hysteria 

One of the symptoms of hysteria is the ten- 
dency, exaggerated above the normal, towards 
interference with the perfect accomplishment 
of volitional acts, and more particularly of 
more or less automatic acts, when the patient's 
attention is directed to their performance. For 
this reason, during examination of visual acu- 
ity, amblyopia may often be noticed in the same 
manner that dyamometric examination may ap- 
pear to indicate that the patient's gripping 
power is greatly diminished. In either case the 
condition is brought about by the tests and 
usually it disappears promptly with the con- 
clusion of the examination. These subjective 
and temporary amblyopias are well known, 
and, in testing the visual acuity of hysteric 
patients, every ophthalmologist employs sug- 
gestion, whether unconsciously or intention- 
ally, in the effort to reassure the patient and to 
induce her to read the letters of just one more 
line lower down on the test card. It is not im- 
possible, too, that tests of visual acuity may 
occasion more persistent amblyopia or amaurosis 
just as perimetric examination of Mabel A. 
eventuated in the production of this symptom. 

Prince has written of a patient whose peculiar 
kind of amblyopia may have been produced 
by an examination of vision. The patient had 
always believed that his vision was good until 
he was examined to determine his fitness for 
appointment to the Boston police force. As the 



The Special Senses 95 

examination showed defective visual acuity, 
each eye being tested separately, he was reject- 
ed. Subsequently, he was examined by Dr. 
Putnam and Dr. Prince who found that while 
binocular vision was 20/15 monocular fixation 
reduced his vision to 17/100 with the left eye, 
and to 17/70 with the right one. (Hysterical 
Monocular Amblyopia Coexisting with Normal 
Binocular Vision, Amer. Jour, of the Med. 
Sciences, Feb. 1897). 

Even a distressing sight may cause amauro- 
sis. Great excitement normally may bring 
about a temporary and more or less complete 
inhibition of vision. In such cases the individ- 
ual asserts that everything became dark, or 
that he acted without being able to see what 
he was doing. When one witnesses a distress- 
ing or revolting scene, there is a tendency to 
shut out the view by closing the eyes, or by 
clapping the hands over them. Consequently, 
when hysteric amaurosis develops after such 
an exposure, the condition seems to be but the 
psychic elaboration of this normal reaction of 
defense. And the dissociation of visual per- 
cepts from consciousness once having occurred, 
the symptom, in a hysteric, would tend to per- 
sist indefinitely. An excellent instance of this 
mode of genesis is afforded by a case which was 
reported by H. Gradle, who writes: "The 
patient, hitherto in good health, had had a 
severe shock to her feelings, . . . , and, 



96 Psychopathology of Hysteria 

clapping her hands to her eyes to shut out the 
sight, found herself absolutely blind." The 
next day, suggestion, reinforced with mild 
faradism, caused the return of conscious 
perception of visual impressions. (Gradle: op. 
cit.). 

In the more pure forms of hysteria the pres- 
ence of amaurosis may not annoy the patient 
nor cause her to be alarmed. In fact, complete 
bilateral amaurosis may not cause any in- 
convenience in some cases, and, in spite of the 
visual loss, the patient may contrive to go 
about as usual; though exhibiting, perhaps, the 
uncertain actions of organic blindness. Be- 
cause of its psychic nature, and in contradistinc- 
tion to most varieties of organic blindness, the 
reflexes of the iris are unimpaired, with but 
few exceptions, and ophthalmologic examina- 
tion fails to reveal any pathologic changes. It 
scarcely need be mentioned that the suddenly 
appearing ambloypias due to toxaemias and to 
exposure to intense light, may not be accom- 
panied with fundus changes, and, therefore, 
these possibilities must be excluded before 
making a diagnosis. Of some diagnostic impor- 
tance is the discovery of corneal anaesthesia 
and of a ring of anaesthesia surrounding the 
eyes. 

While reading a book the attention of a normal 
person may become concentrated upon some ex- 
traneous idea. Subconsciously he continues to 



The Special Senses 97 

read; but when his attention returns to the 
book he finds that he is ignorant of all that he 
had read while his attention was diverted. Now, 
we know that experiments performed under sim- 
ilar circumstances have been successful in caus- 
ing the subject to reproduce the memories of 
events which occurred during distraction of at- 
tention, and we are justified, on these grounds, 
in asserting positively that in the above instance 
it would be possible to effect reproduction of the 
subject matter which was read while the indivi- 
dual was pursuing the extraneous line of 
thought. During distraction of his attention the 
person was not blind ; he continued to read auto- 
matically but the visual perceptions were not 
synthetized with consciousness. Hysteric amau- 
rosis is identical in character. The visual ap- 
paratus of the hysteric is normal, and subcon- 
sciously visual perception occurs, as can be 
demonstrated readily, only she is not attending 
to these perceptions. They remain subconscious ; 
they are not synthetized with consciousness. In 
her case the mental blindness is due to dominant 
belief in her inability to see, and just as soon as 
she can be induced sincerely to expect disap- 
pearance of her blindness it will disappear. 

Let us adduce another common example of 
the psychic blindness of absent-mindedness. 
While walking along the street a person whose 
attention is concentrated upon some problem 
passes his friends, perhaps looking directly at 



98 Psychopathology of Hysteria 

them, yet fails to respond to their salutations. 
Subconsciously he sees them, but there is lack of 
that personal perception which is requisite for 
conscious recognition. In the same manner he 
fails consciously to perceive the many visual im- 
pressions which arise, and he may even walk past 
his destination. 

By means of post-hypnotic suggestion one is 
able to create a psychic blindness which will per- 
sist after the hypnotic state has been caused to 
disappear. When produced in this manner psy- 
chic amaurosis possesses all the characteristics 
of that due to hysteria, and in itself is indistin- 
guishable from hysteric blindness. With the as- 
sistance of hypnotic suggestion, or of post-hyp- 
notic suggestion, one can cure hysteric amauro- 
sis. These facts, together with the known influ- 
ence of extra hypnotic suggestion in causing, 
modifying, and in curing hysteric blindness, 
seem to be sufficient grounds for the proposi- 
tion that hysteric amaurosis, in common with 
other symptoms of the disease, is always the 
effect of expectant attention, suggestion, or 
whatever one wishes to call the process. As 
such, the condition is really the same as that 
produced with hypnosis, from which it differs 
only in its mode of production; the first being 
due to autosuggestion that has been induced 
by some external stimulus, or suggestion, that 
even may have proceeded accidentally from a 
second person, and the other being the direct 



The Special Senses 99 

effect of intentional suggestion by another. 
Otherwise, the nature and mode of genesis of 
inorganic psychic blindness have never been 
explained in a manner that is compatible with 
what now is known of its qualities as revealed 
by experimentation. 

Hysteric monocular amaurosis might be com- 
pared with the habitual suppression of the 
secondary image of diplopia in cases of strabis- 
mus. A more accurate comparison is afforded 
by the voluntary suppression of visual impres- 
sions arising in one eye, when, with the other, 
the pathologist is intently studying some 
specimen with the microscope. 

Even more interesting is hysteric system- 
atized amaurosis, a condition in which lack of 
conscious perception of visual impressions is 
confined to one or more kinds of objects; vision 
otherwise being normal. This symptom, too, 
is but the pathologic exaggeration of what is 
a normal peculiarity. The following citation 
from Jastrow of a normal instance of system- 
atized psychic amaurosis and anesthesia serves 
well to introduce the subject : 

"A business man living in the suburbs, as he 
entered the train upon his homeward journey, 
reflected upon the threatening aspect of the 
sky, and considered the chances of finding his 
carriage awaiting him at the station, in case the 
impending rain came on. His hopes were 
doomed to disappointment; and he resigned 



100 Psych opathology of Hysteria 

himself to a wet walk home. As the downpour 
became heavier, he more keenly regretted his 
wavering hesitation in the morning in regard to 
taking an umbrella. When at length he pre- 
sented himself dripping at his door, he was 
greeted with shouts of derision at his plight; 
for tucked under his arm was the umbrella, 
unopened, unperceived. So convinced had he 
been that he had neglected to provide himself 
with this protection, that the repeated solicita- 
tions to his senses offered by the presence of 
that object passed unheeded. Doubtless, in the 
course of his walk, the umbrella had fallen within 
the range of his vision; and certainly his arm 
had sufficiently attended to the feelings resulting 
from the carrying of the article to prevent its 
being dropped. To these appeals to see and feel 
and recognize did his mental prepossession ren- 
der him blind and insensible. Had any passer- 
by broken through his "absent" spell and 
pointed out his neglected opportunities, he would 
at once, and with some surprise and amusement, 
have seen and felt and consciously used what in 
his reflections he repeatedly longed for: in this 
last consideration lies the normality of the ex- 
perience." (The Subconscious, 1906, p. 306.) 

Now, let us consider a pathologic instance ; one 
described by Morton Prince in his report of the 
Beauchamp case of multiple personality. One of 
the alternating personalities had lost one of Miss 
Beauchamp 's rings. In order to insure the safety 



The Special Senses 101 

of the other two a second personality had strung 
them on a ribbon about her neck. Believing 
that all the rings had been lost Miss B. could 
neither see nor feel the remaining two. Even 
when the rings were struck together she was 
unable to hear the resulting click. 

In these two cases, the one normal and the 
other pathologic, we have to deal with lack of 
synthesis with consciousness of all kinds of sen- 
sory perceptions arising from certain objects — 
an umbrella in the first instance, and a ribbon 
and two rings in the second one. The deficit, 
therefore, is systematized and it involves each 
sense that is stimulated by these objects. In other 
words, owing to a firm conviction the umbrella, 
ribbon, and rings had ceased to exist as far as 
consciousness, only, of the various perceptions of 
each of these objects was concerned. Excluding 
consciousness each of these objects was perceived. 
Otherwise, as Jastrow remarks, how could the 
man have carried his umbrella? And in Miss 
B.'s case a second personality had actually sus- 
pended the rings from her neck. In the normal 
instance the business man was dominated by the 
conviction that he had left his umbrella at home 
with the consequence that all kinds of percep- 
tions arising from the umbrella failed to be 
synthetized with consciousness. In the same way 
Miss B. was dominated by the belief that her 
rings were lost. 

Suppose, now, that a hypnotic subject be given 



102 Psychopathology of Hysteria 

the suggestion that a third person, C, has left 
the room, and that only he and the one who 
induced hypnosis remain. After dissipating the 
hypnotic condition it will be found that the sub- 
ject exhibits a systematized lack of conscious 
perception of all kinds of sensory impressions 
aroused by C, and the resulting condition re- 
sembles that of the business man and of Miss 
Beauchamp. Only in this case the conviction is 
deliberately suggested upon the subject by his 
hypnotizer while in the other instances it arose 
spontaneously. 

The various kinds of systematized deficiency 
of personal perception have been designated 
negative hallucinations. Though convenient, 
this term, originated by Bernheim, has been con- 
sidered inappropriate. More objectionable are 
descriptions in which the lack of conscious per- 
ception of various kinds of sensory impressions 
is said to be due to dissociation of these percepts 
from consciousness. In order that percepts can 
be dissociated antecedent synthesis must have 
occurred, and if dissociation took place after 
synthesis, then the resulting condition would be 
amnesia instead of a disturbance of perception. 

Diagnosis of Binocular Hysteric Amau- 
rosis. Without the use of psychic means it 
may be difficult, indeed, to exclude organic 
blindness. With the assistance of hypnotism 
one may be able to make a positive diag- 
nosis of hysteric amaurosis by means of demon- 



The Special Senses 103 

strating the existence of unconscious vision. 
For the patient, while in the hypnotic state, per- 
haps can be caused consciously to see as well as 
"before the onset of the symptom, and, in addi- 
tion, he may be induced to state the name of an 
object which had been held before his eyes pre- 
vious to hypnosigenesis. 

Excluding the application of hypnosis as a 
diagnostic means there are other tests which may 
not be so successful. A simple one is to have 
the patient look at an open book. Normally 
there is an irresistible tendency for the eyes to 
traverse the page, and if these ocular movements 
occur with the patient one is justified in pre- 
suming that some kind of vision exists. 

By means of having the amblyopic patient 
write automatically Binet succeeds in demon- 
strating subconscious perception of letters which 
are too small for the patient consciously to per- 
ceive; and the writing of these letters proceeds 
while the patient reiterates his inability to recog- 
nize them. (On Double Consciousness, 1905, p. 
32.) 

With the assistance of the method of guessing 
it is possible, sometimes, to secure positive results 
in cases of hysteric amblyopia. Suppose we tell 
a patient whose visual acuity is 10/70 that we 
know she is unable to read the smaller letters 
two lines lower down on the test card, but that 
we desire her simply to make rough guesses of 
these letters as we point to them. Often the 



104 Psychopathology of Hysteria 

guesses are correct, just as in case of anaesthesia 
the number that flashes into the patient's mind 
after we have touched the anaesthetic region a 
certain number of times is the same as the num- 
ber of tactile stimuli. In either case the patient 
declares that she does not see the letters or that 
she has not perceived any sensations in the 
affected region. 

Naturally, it may be possible to improve 
visual acuity by employing suggestion — even 
without induction of the hypnotic state. When 
resort is had to this kind of suggestion it is 
important that the patient should not become 
aware of its use, and, therefore, we must dis- 
guise the suggestions. For example, after 
noting the patient's visual acuity, we tell her 
that different test lenses are to be tried in order 
to determine which improves her vision the 
most. Now, by employing plain glasses while 
making free use of suggestion, it may be noticed 
that vision is materially improved. 

Diagnosis of Monocular Hysteric Amau- 
rosis. As a layman is ignorant of the physi- 
ology of the visual mechanism, unilateral psychic 
blindness, whose character is founded solely 
upon his conceptions of vision, necessarily must 
present some very curious physiological incon- 
sistencies when the condition is subjected to 
various tests. 

In the study of patients with hysteric monocu- 
lar amaurosis even more apparent than with 



The Special Senses 105 

other symptoms of the disease, is the fact that 
the results of experimentation are determined 
almost entirely by the patient 's conception of the 
disturbance with which he is afflicted. He is 
blind in one eye only because he is firmly con- 
vinced that such is the case. Any test which is 
adopted for the purpose of demonstrating vision 
in the amaurotic eye and whose significance is not 
appreciated by the patient will succeed, then, 
for the reason that it does not conflict with his 
belief. We should be able, therefore, to differ- 
entiate readily this visual disturbance from 
organic blindness of one eye. The differentia- 
tion is rendered still more simple by reason of 
the number of excellent tests to which we can 
resort. 

In the presence of binocular single vision 
diplopia occurs when one eyeball is displaced 
by pressure. The same effect may be produced 
more accurately and less rudely if we take ad- 
vantage of the principles of refraction and 
place a prism before one eye. In case of or- 
ganic monocular amaurosis both displacement 
of one eyeball and the use of a prism before 
either eye must necessarily fail to produce 
reduplication of the image. Consequently, if a 
patient with unilateral blindness can be caused 
to experience diplopia by either of these means 
the existence of binocular vision is proven — 
the blindness is psychic. It is possible that the 
test may fail because of lack of synthesis with 



106 Psychopatkology of Hysteria 

consciousness of the perception of the image 
which is on the same side as the amaurotic eye. 
Or, when the prism is used, the two images may 
become fused if the ocular muscles are strong 
enough to counteract the refractive effects of 
the prism. 

A test has been described by Prince that does 
not require any apparatus but which necessi- 
tates care in its application. While the patient 
is reading, a pencil is slipped before the normal 
eye. If the blindness is organic, one or more 
words, being obscured by the pencil, are not 
seen by the patient. If the condition is hysteric 
the patient may continue to read without skip- 
ping any words, thus demonstrating the per- 
ception of visual impressions which could have 
originated only in the blind eye. One must be 
careful to hold the pencil between the normal 
eye and the printed page and to hold it still. 
Likewise the patient's head must not have 
moved during the test. Like other tests this 
one will fail if the patient becomes aware of 
its full significance. To render its performance 
less obvious artifice may be employed. For 
instance, one may disguise the test by saying: 
"When I raise this pencil continue to read, but 
do so more rapidly." Then, apparently as an 
accident, the pencil is raised high enough to be 
in the visual axis of the normal eye. 

Another experiment whose application is 
easy, but which may not yield positive results. 



The Special Senses 107 

is that of Pitres: Even though a screen — a 
blotter for instance — is held vertically between 
the patient's eyes and at right angles against 
his face he may be able to read from a book 
in spite of the fact that one lateral half of the 
page can be seen only with the amaurotic eye. 
If the screen is not held perpendicular to the 
center of the page the results are vitiated. 

Monocular amaurosis must be psychic if the 
patient, when looking through a stereoscope, 
acknowledges that the picture stands out in 
relief, because the successful use of this con- 
trivance requires binocular single vision. Be- 
sides these simple measures, tests dependent 
upon hypnosis, and similar to those employed 
in detection of hysteric binocular amaurosis, 
can be applied with positive results in many 
cases. 

With the assistance of special apparatus suc- 
cessful results are more apt to be secured. 
Stoeber's ingenious device comprises a pair of 
spectacles containing one red and one green 
glass, and an object consisting of a printed 
word, of which the letters are alternately red 
and green upon a black background. When a 
patient with organic blindness fixes the object 
through these glasses he can read only those 
letters whose color is the same as that of the 
glass which covers the normal eye. If a pa- 
tient is able to read the whole word then his 



108 Psychopathology of Hysteria 

visual defect either is due to hysteria or it is 
feigned. 

When the box of Flees is used what is seen 
with one eye appears to have been seen with 
the other, so that the hysteric reports having 
observed either both objects or only the one 
which, in reality, was seen with the amaurotic 
eye. The malingerer asserts that he noticed 
but one object, and he indicates the one which 
we know could have been seen only with the 
eye which he affirms is blind. While the indi- 
vidual with organic monocular amaurosis re- 
ports having observed an object which, to his 
surprise, appeared to have been seen with his 
blind eye. 

Unfortunately, the results of these experi- 
ments, except those dependent upon hypnosis, 
may be the same as the results obtained with 
malingerers. As far as the tests themselves are 
concerned there may not be any way of differ- 
entiating the two conditions and the diagno- 
sis may depend entirely upon associated symp- 
toms and upon the experience of the examiner. 
In commenting upon this diagnostic difficulty 
H. Gradle writes: "The distinction between 
hysteric — or let us say psychic — blindness and 
wilful simulation can not be based upon objec- 
tive findings. They would be the same in 
both cases. We must base our judgment on a 
psj^chologic analysis of the patient's mind and 
object." 



The Special Senses 109 

If the utmost care is not exercised in making 
the tests the answers of a clever malingerer, or 
of a simulating hysteric, may be the same as 
those of a patient with organic monocular 
amaurosis. In either case the subject may be 
enabled to do this if he has the opportunity 
furtively to close the supposedly blind eye and 
thus to acquire information concerning what 
should be seen were his feigned symptom real. 
Or, if intelligent, he may be able to grasp the 
significance of certain of the tests. As a 
hypnotized malingerer ordinarily would not 
acknowledge that previous to the induction of 
hypnosis he had seen an object with his "blind" 
eye such a test would be useful; unless we 
accept as true the fallacy that a hypnotized 
person always must tell the truth. 

The results, too, of the tests that have been 
described may appear positively to prove that 
hysteric unilateral blindness is only a feigned 
symptom! But how can we account for those 
cases in which the condition persists for years 
in patients who do not have any motive for 
simulation, or who have excellent reasons for 
desiring that their vision should be normal? 
For instance, Prince's amblyopic patient had 
gone to much trouble in his attempt to qualify 
for appointment to the police force. As he de- 
sired this appointment it was not to his inter- 
est to simulate defective vision. Yet the tests 
seemed to indicate that he was deliberately 



110 Psychopathology of Hysteria 

malingering; provided that one disregards the 
fact that the same results could be obtained in 
hysteria. This patient had perfect binocular 
vision but each eye separately was amblyopic. 
A prism having been slipped before either eye 
during binocular fixation amblyopia developed 
at once. Now, the patient once having reacted 
in this manner the same results were obtained 
when two prisms were placed together so as to 
counteract each other and then held before his 
eye. One who failed to consider the patho- 
genic influence of belief would conclude at once 
that this patient was a malingerer. 

According to de Schweinitz hysteric amauro- 
sis may last even as long as ten years, though 
vision has ultimately returned in all recorded 
cases. When the patient comes under treat- 
ment before the condition has had time to be- 
come fixed, removal of the symptom is com- 
paratively easy. 

In addition to its diagnostic value, hypnotic 
suggestion possesses great therapeutic efficiency. 
Even though the patient be not hypnotized syn- 
thesis of the visual function with consciousness 
possibly may be effected without difficulty by 
means of suggestion. In case suggestion is em- 
ployed the various suggestions should be made as 
positive as possible without, however, allowing 
the patient to become aware of its use. The 
necessity for this lies in the fact that the more 
apparent and more direct the suggestion the 



The Special Senses 111 

more inclined is a hypnotized patient to accept 
and to act upon it, while in the application of 
suggestion to one who is not hypnotized, the 
chances of successful realization vary directly 
with the patient's ignorance of its employment. 

The effect of suggestive treatment is mate- 
rially increased when the suggestions are rein- 
forced and disguised by the use of such an im- 
pressive agent as electricity. The physician 
suggests, for instance, that the blindness will 
disappear when the electrode is applied. Or 
the patient may be placed in a dark room, and, 
after having received an electrical treatment, 
her eyes are bandaged while she is assured 
that her sight will be normal when the 
bandages are removed the next morning. 

As each therapeutic failure tends to convince 
the patient of the incurable nature of her mal- 
ady it is best not to incur this risk and to waste 
valuable time by holding hypnotism in reserve. 
Instead of waiting until other measures have 
failed we should use first, as J. Arthur Booth 
has recommended, the therapeutic resource 
which offers the greatest possible chance of 
success; and this is hypnotic suggestion — the 
most effective kind of suggestion. (Hysterical 
Amblyopia and Amaurosis — Report of Five 
Cases Treated with Hypnotism, Med. Rec, Aug. 
24, 1895.) 

Dyschromatopsia. In the same manner 
that complete amaurosis occurs so also does 



112 Psychopatliology of Hysteria 

psychic blindness for colors — achromatopsia. 
To the achromatopic patient all colors appear 
grey. The oft quoted experiments of Parinaud 
show that hysteric achromatopsia is entirely a 
psychic disturbance. In case of monocular 
color blindness a green object appears to be 
grey when seen by the achromatopic eye. Now, 
if diplopia is produced by placing a prism be- 
fore the normal eye the patient may declare 
that both images are green, as they really are. 
But, the production of diplopia necessitates 
vision with both eyes. Therefore, perception of 
one of the images is dependent upon an eye 
which is color blind. If the patient states that 
both images are grey then the use of the prism 
has effected a temporary achromatopsia of the 
normal eye. When the prism is placed before 
the achromatopic eye the patient declares either 
that both images are grey or that they are 
green. Naturally, these results imply the same 
peculiarities of perception as did ,the results 
obtained when the prism was placed before the 
normal eye. 

Bernheim was the first to show that achroma- 
topsia could be caused by means of hypnotic 
suggestion, and that when thus produced the 
condition experimentally is identical with that 
of hysteria. Discarding, therefore, the involved 
explanation of Parinaud he contended that both 
hysteric and hypnotic achromatopsia were the 
product of suggestion. In this he is sustained 
by the modern French neurologists. 



The Special Senses 113 

When there is total lack of synthesis with con- 
sciousness of perceptions of only one kind of 
color impressions the cause of the defect should 
be readily discovered. A hysteric who has had 
some terrifying or disagreeable experience may 
afterwards develop achromatopsia for one color 
which was prominently identified with the pain- 
ful experience. This partial achromatopsia con- 
stitutes part of a reaction of defense for the 
reason that the memory complex concerning the 
experience has been dissociated from conscious- 
ness and as conscious perception of the color 
would subsequently tend, by association of ideas, 
to recall the dissociated complex these percep- 
tions are also repressed. 

In these cases, too, the disturbance can be 
demonstrated to be psychic in nature. The neat 
experiments of Charcot and Regnard suffice. 
These depend upon the principles of fusion of 
colors. When red and green are fused by me- 
chanical means — rotating disc — the patient with 
monocular blindness for green declares that she 
sees a greyish tint. Now, such a tint, under these 
circumstances, requires the perception of its 
green constituent; otherwise, the patient, per- 
ceiving green as white, should see light red as 
the result of fusion of red and green. 

The different kinds of psychic disturbance of 
color perception are very infrequent in this 
country. May not the reason for this depend 
upon the fact that physicians of this country do 



114 Psychopatholagy of Hysteria 

not usually include in their examinations tests 
of color perception? Therefore, dyschroma- 
topsias not being sought they are less apt to be 
accidently suggested upon the patient. 

Concentric Contraction of the Visual 
Fields. This "symptom," one of the classic 
"stigmata" of hysteria, was considered to pos- 
sess considerable diagnostic importance. It is 
probable, however, that it is always caused 
by suggestion during perimetric examinations 
and, consequently, it is indicative only of 
the abnormal suggestibility which is essential to 
hysteria but which also occurs in other psycho- 
neuroses. In reference to 86 cases reported from 
Bernheim's clinic Amselle states that not even 
once were hemianesthesia and retraction of the 
visual fields discovered in patients who had not 
been examined previously. (Conception de 
l'Hysterie, p. 237,1907.) 

That concentric contraction of the visual fields 
is not a spontaneous symptom of hysteria can 
be reasonably ascribed to the improbability that 
a layman could conceive such a condition. As 
the symptoms of hysteria are dependent either 
upon the conceptions of the patient or upon 
accidental suggestion — using this term in its 
most comprehensive sense — one might lay down 
the axiom that the hysteric is incapable of pre- 
senting any symptom of which previously she 
did not have some conception, or which was not 
suggested upon her. Neither can one experience 



The Special Senses 115 

a dream whose content is independent of all 
previous knowledge, nor can one cause a hyp- 
notic subject to hallucinate an object which he 
had never perceived. 

It is not intended to convey the impression 
that concentric contraction of the visual fields 
is always created by reason of a faulty technique 
of examination, but that the examination per se 
is sufficiently suggestive to determine the pro- 
duction of this condition unless the physician 
employs suggestion in order to counteract the 
tendency. Except those patients whose fields 
previously have been examined, it is most un- 
usual to find contraction of the fields in hysterics 
who are examined with the rough finger test, 
provided that this is performed in a manner 
that is not too elaborate nor too prolonged. 
With the perimeter, an imposing and suggestive 
apparatus and one which requires that the 
patient be subjected to an unduly prolonged 
examination, it is rare, indeed, not to find mod- 
erate or high grade contraction of the fields 
unless the physician, by his antagonistic sug- 
gestions, prevents the production of the condi- 
tion. 

During former investigations of the visual 
fields it was my custom to eliminate verbal sug- 
tion, at least, by explaining to the patient just 
what was required; stress being laid upon the 
injunction that she was to say "now" just as soon 
as she saw the peripheral white spot. Then the 



116 Psychopathology of Hysteria 

examination was commenced and finished with- 
out further directions or remarks. In this man- 
ner suggestions, whether tending to cause or to 
prevent the production of concentric contrac- 
tion, are avoided and only the suggestive char- 
acter of the examination itself remains. Under 
such conditions reduction of the visual fields 
varying from a moderate amount to contractions 
so extreme as to indicate pin-point vision were 
invariably found; even though previous rough 
finger tests showed, in almost every case, that 
the fields were approximately normal. 

On the other hand, if the physician desires to 
avoid the production of concentric contraction 
it is easy to do so by means of suggestion and 
persuasion during the course of the examina- 
tion. By this means distraction of the patient's 
attention is avoided, she is induced to attend 
strictly to peripheral vision, and, in addition, if 
vision at any one radius does not correspond to 
the normal she is assured that she can do better 
than that and the test is repeated. When this 
technique is adopted concentric contraction of 
the visual fields rarely will be found in cases 
whose fields are being examined for the first 
time. 

In order to prove that hysteric contraction of 
the fields was only subjective it was my custom 
to hold up several fingers in the arc of the peri- 
meter well beyond the limit of the field which 
had been previously determined. Upon asking 



The Special Senses 117 

the patient if she saw the fingers the reply 
would be negative. Then, resorting to hypnosis, 
it was usually easy to induce her to state just 
how many fingers she had seen in the supposedly 
blind portion of her field. I soon found, how- 
ever, that hypnosis was unnecessary; for it was 
much easier simply to ask her in a positive man- 
ner how many fingers she saw. Since adopting 
this procedure not one of perhaps 25 consecu- 
tive cases of hysteria has failed to answer cor- 
rectly the majority or all of the times that the 
test was repeated. 

Such a test, which is but one of many similar 
ones which may be employed, experimentally 
proves at once that hysteric concentric contrac- 
tion of the visual fields is only a psychic dis- 
turbance. Clinically, this fact has been known 
for many years. How, otherwise, could we ex- 
plain the following case described by Janet : A 
boy who developed crises whenever he saw a 
flame, possessed visual fields which were con- 
tracted to 5°, yet a crisis could be precipitated 
by holding a lighted match at 80° while the 
patient was at the perimeter and fixing its cen- 
tral point. (Major Symptoms of Hysteria, p. 
197.) How, too, could we account for the fact 
that there is not any embarrassment of the 
actions of those patients whose fields are con- 
tracted to a point, and in whom the condition 
has been fixed by repeated examinations and 
clinical demonstrations. In reference to this 



118 Psychopathology of Hysteria 

anomaly Janet writes of a patient who was able 
to play at ball in spite of an extreme degree of 
contraction of the fields. It would be hardly 
necessary to state that this would be absolutely 
impossible in case of organic contraction to the 
same degree. Try to imagine anyone playing 
ball while looking through a pair of telescopes 
or a double barrelled gun! 

In spite of the laws of optics a contracted field 
of hysteric origin remains the same regardless 
of any increase of the distance at which it is 
taken ; instead of enlarging, as it should. Natu- 
rally, this inconsistency depends upon the con- 
ception of the visual defect that the patient 
formed during the first perimetric examination. 
Being ignorant of optics she believes that the 
area which she can see should remain the same 
whether she is fixing upon an object one foot 
away, or on one which is at a distance of 20 
feet. It was remarked, also, that the size of the 
field could be made to vary according to the 
use of suggestion by the examiner, and accord- 
ing to the mental state of the patient while 
being examined. By causing the patient to con- 
centrate her attention upon some problem Janet 
secured variations amounting to as much as 60°. 
Finally, it is possible, with hypnotic suggestion 
in almost all cases and with suggestion during 
the usual state of consciousness of the patient in 
most cases, to enlarge, perhaps even to the 
normal, a contracted field. Likewise, one may 



The Special Senses 119 

•create a contraction in patients whose fields 
previously had been normal. 

From a diagnostic point of view there should 
not be the slightest difficulty in differentiating 
the concentric contraction of hysteria from the 
infrequently encountered similar visual defect 
of multiple sclerosis, or the quite common one 
of tabes dorsalis — 50% of 25 cases in which the 
disease had existed for an average of 5% years 
— and of other varieties of optic atrophy. 

The advisability of producing contraction in 
hysteric patients is decidedly questionable; 
though apparently they do not seem to incon- 
venience or to harm the patient in any way, 
considered as a means of diagnosis the field 
changes that have been described can be re- 
garded only as indicative of abnormal sug- 
gestibility and not as essential symptoms of 
the disease. Furthermore, the functional con- 
traction which is elicited by examination is by 
no means pathognomonic of hysteria; in the 
other psj^choneuroses it can be observed just 
as frequently, but usually not to such an ex- 
treme degree as we find in some cases of 
hysteria. 

Ordinarily, it is thought that spiral fields are 
characteristic of neurasthenia, and that the 
condition is due to progressive fatigue occa- 
sioned by the examination. In hysteria, never- 
theless, spiral fields are created more commonly 
than in neurasthenia when the perimetric ex- 



120 Psychopathology of Hysteria 

animation is conducted according to the tech- 
nique which I have described. Moreover, fields, 
which are concentrically contracted may be 
changed into spiral fields solely as the effect 
of the manner in which the patient is ques- 
tioned during repetition of the examination. 
Let me adduce a typical example: 

As examined by the rough finger test, the 
visual fields of Lizzie B. were approximately 
normal; perimetric examination, however, re- 
sulted in production of spiral fields of small 
amplitude. Being so marked, the contraction 
could not have escaped detection by the finger 
test; consequently, it must have been caused 
by the perimeter. During the same visit, re- 
examination resulted in diminution of the fields 
to a point. Seven days later the fields were 
found to have remained unchanged. After 
about six months had passed, she was subjected 
to a third perimetric examination. Commenc- 
ing at 0° and progressing rapidly from the 
nasal to the temporal fields, the tests were made 
30° apart in order not unduly to prolong the 
examination. After one complete circuit of the 
left eye she was allowed to rest five minutes, 
and then the right field was taken. Although 
hysteria is characterized by the opposite of 
abnormal readiness to the induction of fatigue, 
periods of rest were allowed on returning to 
the left eye, at the termination of each complete 
circuit. Proceeding in this manner, the spiral 



The Special Senses 121 

field which was produced could not have been 
due to transient fatigue. Being able, after- 
wards, correctly to count fingers which were 
held in the arc of the perimeter at the periphery 
of what should be the normal field, she was 
given a brief explanation of the fields of vision, 
and, furthermore, the inconsistency of the re- 
sults in her case was demonstrated to her. Now, 
upon repeating the examination, her fields were 
found to be practically normal. Repeated 
single tests which were without definite radial 
sequence verified the boundaries of these fields. 
When produced by the technique already de- 
scribed both spiral fields and the fact that, in 
case of concentric contraction, the field of the 
second eye examined is usually smaller than 
that of the first, can be explained acceptably by 
assuming that the further one proceeds with the 
examination the better able is the patient to grasp 
the suggestion which it implies, and, conse- 
quently, the more forcible it becomes. This 
cumulative effect of the suggestive nature of 
perimetric examination is like the cumulative 
effect of suggestions during the hypnotic state. 
When a hypnotized subject refuses at first to 
accept a suggestion often it is necessary only 
that it should be repeated several times, and 
with each repetition one can plainly see that the 
resistance of the subject is decreased until, fin- 
ally, the suggestion is accepted and acted upon. 



122 Psych opathology of Hysteria 

The Color Fields. As investigations of 
the color fields require extended perimetric ex- 
amination, and as it is extremely difficult to 
induce a hysteric to concentrate her attention 
upon one subject for any length of time, such 
investigations necessarily must be extremely 
variable in their results; even more so than we 
find in our examinations of the fields for white. 

It is well known that the size of the visual 
fields of a hysteric to a great degree is de- 
pendent upon suggestion and upon the amount 
of concentration of the patient's attention on 
the examination; distraction of her attention 
being accompanied by reduction in the size of 
the field which is being examined at the time. 
Whenever the patient becomes preoccupied with 
some extraneous idea, or whenever her atten- 
tion is distracted by some noise, someone enter- 
ing the room, or what not, we notice correspond- 
ing modifications in the size of the visual field. 
We may find, therefore, that the field for red 
is larger than that for blue simply because the 
patient's attention was concentrated upon the 
examination while she was being tested with the 
first color, whereas her attention was distracted 
during the tests with blue. Moreover, being pro- 
longed the examination is apt to arouse a state 
of indifference, or of active rebellion, with the 
consequence that each successive field may be- 
come smaller. The cumulative effects of the 
suggestive character of the examination tend to 



The Special Senses 123 

produce the same sequential modification. A 
priori, then, one should not expect to find any 
typical or constant relative disturbance of the 
color fields. Clinically, this inference receives 
abundant verification. 

In their mode of production contractions in 
the color fields need not be considered as differ- 
ing in any way from contraction of the field for 
white; all such contractions being the effect of 
the increased suggestibility characteristic of 
hysteria. It has been considered that inversion 
of the color fields was a prerogative of hysteria. 
Of the greatest importance, therefore, are the 
findings of Bordley and Cushing relative to the 
color fields in cases of brain tumor. Their in- 
vestigations show that inversion is just as char- 
acteristic of brain tumor as it has been con- 
sidered to be of hysteria. (Archives of Ophthal., 
Sept., 1909.) In a later paper Cushing and 
Heuer (Jour, of the A. M. A. 1911, 2, p. 200) 
state that out of 123 patients with brain tumor 
in which perimetric examination could be made 
there were 53 who presented contraction and in- 
version of the color fields, and, what is more 
important, in ten of these the disturbances 
occurred in the absence of choked disc, or else 
only a very incipient process was found. On 
the other hand, one must not forget the fre- 
quency with which symptoms of hysteria, as 
Gowers has remarked, are painted upon a back- 
ground of organic disease, and thus to ascribe 



124 Psychopathology of Hysteria 

to brain tumor symptoms which may have been 
the effect of increased suggestibility due to super- 
imposed hysteria. 

Hemianopsia. That hemianopsia ever occurs 
as a symptom of hysteria has been the subject 
of controversy. At all events, a few cases have 
been reported, and besides, there is no good 
reason for assuming that this type of de- 
fect in the visual field cannot develop. The 
infrequent occurrence of hysteric hemianopsia 
can be explained on the grounds that laymen 
do not possess knowledge of the difference in the 
cerebral distribution of fibres from different 
parts of the retina, and, therefore, they cannot 
have any conception of hemianopsia. Moreover, 
perimetric examination, as usually conducted, 
tends to cause general reduction of the fields 
and can hardly convey to the patient the sug- 
gestion of hemianopsia. 

In about 50% of those afflicted with migraine 
the attack is preceded by some visual disturb- 
ance. Quite commonly this assumes the form of 
a scintillating scotoma which may produce com- 
plete but transient hemianopsia. Now, is it not 
reasonable to assume that a hysteric who in this 
manner has acquired knowledge of homonymous 
hemianopsia subsequently may develop hysteric 
hemianopsia ? May not the symptom of migraine 
or of auto-intoxication become fixed as a result 
of the tendency of hysteria to appropriate and 
to elaborate the symptoms of other diseases ? At 



The Special Senses 125 

any rate, one patient stated that shortly before 
psychic homonymous hemianopsia appeared she 
had experienced for the first time a scintillating 
scotoma which had obscured the same half of 
her visual field. If hysteria were more com- 
monly associated with true migraine probably 
hysteric hemianopsia would be less infrequent. 

A second patient declared that she had been 
well until her fifteenth year when suddenly she 
lost the ability to see anything to one side of 
the point at which she was looking. Without 
being prompted she explained in detail the na- 
ture of this difficulty. Careful inquiry failed 
to disclose the cause of the symptom ; she had 
never experienced a scintillating scotoma, and, 
before the onset of the symptom, her eyes had 
not been examined. Following the first attack 
of hemianopsia she had been subject, for a 
whole year, to other ones that lasted about 
twenty minutes and which occurred several 
times daily. Beginning with this visual dis- 
turbance a most severe type of major hysteria 
became evolved. 

Deafness. In hysteria, whatever is done 
or perceived in a more or less unconscious or 
automatic manner is apt to be accomplished or 
perceived better than when the act receives the 
conscious attention of the patient. On account 
of this, together, perhaps, with the effects of 
the suggestion implied by the test, hysteric pa- 
tients who present evidences of possessing an 



126 Psychopathology of Hysteria 

ordinary amount of strength almost invariably 
are incapable of registering on the dynamome- 
ter a degree of strength greater than that of a 
child. Or, when testing vision, conscious per- 
ception of the test letters may be no better 
than 10/50, yet, at other times, visual acuity of 
the same patient is obviously normal. In the 
same manner hysteric patients whose hearing 
evidently is normal almost always show, when 
tested, decided reduction of acuity of audition ; 
unless this functional impairment is prevented 
by suggestion. 

Suppose we subject a number of hysterics to 
an examination in which the following tech- 
nique be employed: The patients are directed 
to declare when they hear the watch, and then 
no other remarks are made during the course of 
the test. Each ear is tested by gradually bring- 
ing a watch from an inaudible distance towards 
the ear. It will be found that with a watch 
that should be heard at about three feet, in the 
neighborhood of 90% of the patients do not 
detect the ticking at a distance greater than 
about five inches, and approximately 10% re- 
quire the watch to be placed in contact with 
the ear. 

Having examined a hysteric who asserts that 
she is unable to hear the watch until it is; 
placed in contact with her ear, and having had 
her close her eyes, let us hold the watch sta- 
tionary at almost the extreme limit at which 



The Special Senses 127 

it should be heard. Now, by asking at fre- 
quent intervals, "Do you hear it yet?", the im- 
pression is conveyed that the watch is being 
gradually brought closer to her ear, as it was 
during the first test. After a few such ques- 
tions the patient announces that she perceives 
the ticking. In the absence of an organic 
cause for the impairment this experiment in my 
hands has failed to succeed in only two in- 
stances. In a few cases, however, before a 
positive response can be obtained it may be 
necessary to bring some metallic object into 
contact with the patient's ear, thus causing her 
to believe that it is the watch which she feels. 
Having demonstrated the subjective nature of 
the reduction in hearing, and while retaining 
the watch in the same position, the patient is 
told to open her eyes. Being aware of the 
deficiency brought about by the first test, she 
at once expresses surprise at the distance at 
which she heard the watch, and, what is impor- 
tant, she continues to hear it at the same dis- 
tance. 

In testing with the Galton whistle often we 
find that the highest notes are not consciously 
perceived by the patient, but this has the same 
significance as the defects brought about by 
testing acuity of audition, or of vision. Occa- 
sionally, it is possible to demonstrate very 
nicely with the Galton whistle the pathogenic 
effects of a suggestive technique of examina- 



128 PsycJiopathology of Hysteria 

tion. The patient is told to apprise us when she 
begins to hear the whistle, and then, progres- 
sively lowering the pitch from the extreme 
limit of normal audibility, we find that she fails 
to hear the whistle until a note of, for instance, 
21,000 vibrations is obtained. Now, suppose 
we instruct her to notify us when she is not 
able any longer to hear the whistle. Continu- 
ing gradually to lower the pitch, infrequently 
we may find that she is unable to hear a note 
whose vibrations are less, for example, than 
10,500. No other interpretation can be placed 
upon such curious results than that they were 
determined entirely by suggestion. 

In addition to these rudimentary and practi- 
cally inocuous kinds of temporary disturbance 
of auditory perception, complete unilateral or 
bilateral psychic deafness is uncommonly en- 
countered. When unilateral, psychic deafness, 
like hysteric monocular amaurosis, may occur in 
association with hemianassthesia and other dis- 
turbances of perception of sensory impressions 
arising from the same side of the body; the 
association of these symptoms being due solely 
to the patient's belief that hemianaesthesia 
must necessarily include homolateral loss of all 
forms of sensibility. 

When occurring independently of hemi- 
anaesthesia, unilateral psychic deafness is often 
evolved from some unimportant local affection 
which concentrates the patient's attention upon 



The Special Senses 129 

her ear, and upon hearing, or it may be the 
consequence of the psychic effects of trauma- 
tism to the ear. 

The history of one patient showed that the 
condition had developed from what presum- 
ably was a furuncle of the external auditory 
canal. Two years after the onset, a compe- 
tent otologist, finding that the auditory ap- 
paratus was normal, advised her to consult a 
neurologist. When engaged in conversation, 
the patient did not appear to be inconvenienced 
except when her attention was directed to her 
hearing. Then, turning her sound ear towards 
the person with whom she was conversing, she 
seemed to experience difficulty in perceiving 
what was said, and occasionally she required 
that a sentence be repeated. When tested with 
the fork, she asserted that she was unable to 
hear either by osseous or aerial conduction. 
With the exception of the psychoneuroses such 
a finding indicates organic nerve deafness. But, 
when the auditory apparatus of only one side 
is the seat of organic nerve deafness, osseous 
conduction is not entirely lost because the 
vibrations are transmitted across the skull to 
the opposite side. 

When examining patients with psychic deaf- 
ness, the results of tests necessarily must be in 
accordance with the patient's conception of 
deafness. Consequently, all kinds of auditory 
impressions, whether these be the product of 



130 Psychopathology of Hysteria 

aerial or of osseous conduction, fail to be syn- 
thetized with consciousness — they lack personal 
perception. If a hypnotized subject accepts the 
suggestion that he cannot hear with one ear, 
one will find that the same results are obtained 
with the fork. In addition to those patients 
who present loss of both forms of sensibility 
occasionally we find one in whom the tests show 
apparent loss of osseous conduction with pres- 
ervation of aerial conduction. This finding can 
occur only as a result of suggestion in psycho- 
neurotic patients. 

Reverting to our patient, after inducing the 
hypnotic state, it was easy to effect partial 
return of bone conduction. After a few subse- 
quent treatments, air conduction at first was 
secured, and then caused progressively to im- 
prove until it became normal. During the fol- 
lowing eighteen months that she was under 
observation not any further auditory difficulty 
was experienced. 

The occasional association of deafness and 
mutism is probably due to the popular knowl- 
edge of the frequency with which mutism 
occurs as a complication of organic deafness. 
In the case of Mabel A., total psychic deafness, 
associated with mutism, suddenly developed 
without any ascertainable cause. After lasting 
four days, speech and hearing returned, but 
for over a month, attacks of deaf-mutism re- 
curred every afternoon at the same hour that 



The Special Senses 131 

the first attack had appeared. Save the initial 
alarm at the sudden appearance of these major 
symptoms, she was not disturbed in any way, 
and, in fact, she was reluctant to consult 
a physician. During the first attack, aerial and 
bone conduction were absent, and she seemed 
totally unable to speak or to hear. In this 
case, too, the symptoms were readily influenced 
by hypnotic suggestion — adopted on the nine- 
teenth day — and, after two treatments, the at- 
tacks no longer recurred. 

The psychic nature of hysteric disturbances 
of sensory perception are well illustrated by 
Oettinger's interesting case. After a period of 
auto-hypnotic sleep, this patient exhibited deaf- 
mutism which persisted for over four months. 
In explanation of his comprehension of what 
was said to him, he asserted, in writing, that 
he could read the lips of those who talked to 
him, yet it was found that he was unable to 
read the lips during silent speech. Further- 
more, when the babies cried in the children's 
ward he volunteered his services, though he could 
obtain knowledge of the opportunity for his 
assistance only by hearing the crying. Several 
other inconsistencies were also apparent. The 
symptoms disappeared spontaneously in this 
case; faradism having been ineffectual and 
efforts to hypnotize him having proved fruitless. 
Afterwards, he spoke complacently of his suc- 
cessful resistance to suggestion. (Jour, of Nerv. 
and Ment. Dis., 1908, p. 129.) 



132 Psychopathology of Hysteria 

The character of the disturbance has been 
ludicrous in some of the recorded cases of hys- 
teric deafness. Knapp's case, for example, was 
treated for a couple of weeks with suggestive 
applications of f aradism with the result that her 
complete deafness was changed to word deaf- 
ness. The peculiarity consisted in her ability 
to hear her own voice, though unable to hear 
the voices of others. Further improvement hav- 
ing taken place, she became able to hear the 
voices of females, but psychic deafness for male 
voices continued to exist. (Monatsschr. f. 
Psychiat. u. Neur., Dec, 1907.) 

The distinction between organic deafness and 
that due to hysteria should not be difficult. 
Sometimes one can startle the patient into dis- 
closing her consciousness of a noise. This pro- 
cedure, however, not only is crude but it should 
succeed only in cases of malingering, or of hys- 
teric malingering. A better method is to at- 
tempt to produce, by suggestion, subconscious 
reaction to auditory stimuli. One may succeed 
in demonstrating that a case of deafness is not 
organic by means of another device which is 
dependent upon suggestion. In the presence 
of the patient the physician, after having deter- 
mined that what he is about to suggest is not 
already present, incidentally remarks to who- 
ever happens to be present that the patient 
should present such and such a sign. If the 
case is one of hysteria, subsequent examination 



The Special Senses 133 

may show that, in the interval, the patient has 
developed the sign which she has been induced 
to believe is essential to her disease. Finally, 
with suggestion it may be possible at once par- 
tially or completely to restore normal hearing. 

Smell and Taste. Psychic anosmia and psy- 
chic ageusia are encountered less frequent- 
ly than similar disturbances of vision and of 
audition because the senses of smell and of 
taste are rarely examined by physicians, and, 
therefore, these conditions are not so liable to 
be produced as artefacts. Probably the major- 
ity of cases of unilateral anosmia and ageusia 
are only part of hemianesthesia, and the asso- 
ciation of the symptoms is the consequence of 
the patient 's conception of hemianesthesia. By 
reason of his faulty technique of examination 
some physician creates hemianesthesia, and 
then he, or some other one, discovers by fur- 
ther tests that the patient has homolateral 
deafness, amaurosis, anosmia, and ageusia. 

When cases of anosmia and ageusia are sub- 
jected to critical examination the results, from 
a physiologic standpoint, are remarkable. Mary 
D., for example, never had been aware of any 
disturbance of sensory perception until a phy- 
sician had "discovered" hemianesthesia and 
hemianalgesia. Months afterwards she was 
unable, during my tests at least, consciously to 
perceive tactile, thermal, painful, or pressure 
stimuli applied to the right side. The other 



134 Psychopathology of Hysteria 

physicians who had examined her had not 
tested her special senses, and, as far as she was 
aware, these had not been impaired. My ex- 
amination, conducted in the usual manner, i. e., 
without attempting to avoid the production of 
symptoms, showed unilateral deficiency of all 
the special senses of the right side, Therefore, 
either these troubles had existed unbeknownst 
to her, or my examination was their sole cause. 
At any rate, though olfaction by means of the 
left nostril was not impaired she asserted that 
she was unable to perceive any odor when she 
smelled various test substances while the left 
nostril was occluded. Except as a manifesta- 
tion of hysteria this condition would be most 
remarkable, indeed, for even if the odors were 
received only through the nostril of the affected 
side unilateral anosmia could not cause total 
abolition of the sense of smell. Not only would 
the posterior naris of the sound side aid in 
detection of the odor, but, with some odors, the 
associated sense of taste alone would be suffi- 
cient. 

From a physiological point of view even 
more extraordinary is the fact that inhalation 
of ammonia through the right nostril was 
absolutely devoid of reaction. As a conse- 
quence, then, of her firm conviction that she 
was unable to smell with her right nostril, there 
results associated immunity from the usual 
effects of ammonia upon respiration. This in- 



The Special Senses 135 

stance of the total inhibition of the effects of 
such a powerful respiratory stimulant is a re- 
markable, but not unique, example of the exalt- 
ed power, in hysteria, of the mind over the 
body. 
t In the same patient the substances usually 
employed for testing the gustatory sense were 
readily perceived when applied to the left side 
of the tongue. On the otherside, however, they 
were not detected until the tongue was with- 
drawn, and then only with difficulty, or not 
at all. In addition to unilateral anosmia and 
unilateral ageusia, this patient had almost com- 
plete monocular amaurosis — V. 0. D. 4/200 — 
unilateral deafness, and incomplete hemiplegia. 



CHAPTER V 

Visceral and Circulatory Derangements 

RESPIRATORY System. Except com- 
plete cessation of breathing hysteria 
can occasion all the possible vari- 
ations of respiration. The atten- 
tion of the patient may have been concen- 
trated upon the respiratory effects of great 
excitement with the consequence that these 
normal reactions have become fixed as symp- 
toms of hysteria. Or, the respiratory symp- 
toms resulting from accidental and transient 
organic disease may be prolonged in the same 
manner. There is a tendency for a hysteric to 
develop the symptoms with which she is most 
familiar, so that long after having become 
acquainted with the symptoms which resulted 
from some organic disease, or from excitement, 
these may return as hysteric manifestations 
consequent upon some psychic trauma which 
she has undergone. In this case the relation 
between the exciting cause and its effect is dif- 
ficult to understand unless the former incident 
is known. 

Naturally the frequency of respiration be- 
comes increased during convulsive and emo- 
tional attacks, but sometimes the symptom oc- 
curs independently, and it may persist for 
weeks. Often it is paroxysmal ; recurrences 

136 



Visceral and Circulatory Derangements 137 

being effected by mental . stresses. The rate 
may be increased to an extent which can be 
scarcely credited. In a case recorded by Char- 
cot respiration attained a frequency of 180 per 
minute. During hysteric "coma" brought 
about by a mental shock one patient who came 
under my observation exhibited a respiratory 
rate of 120 for several hours, over 100 for more 
than a day, and between 80 and 108 for several 
days. A few days later a second attack de- 
veloped, and during five consecutive days respi- 
ration was maintained between 50 and 80. It 
is remarkable, indeed, that such a rate could 
have been maintained for this length of time. 
One has only to attempt voluntarily to breathe 
this rapidly in order at once to discover how 
difficult and how exhausting it is. 

Spasmodic disturbances of respiration are 
usually due to true volitional tics of the respi- 
ratory muscles, and they occur in patients who 
do not present any of the signs of hysteria, but 
rather those of psychasthenia. These tics, like 
similar ones in other parts of the body, are 
produced by obsessions which the patient is 
impelled to gratify, and they are accompanied 
by self-consciousness and shame. Generally 
speaking, spasmodic disturbances of breathing 
are not due to psychasthenia when they cannot 
be voluntarily duplicated. For instance, one 
never encounters attacks of sneezing or of true 
singultus in typical psychasthenics. The 



138 Psychopathology of Hysteria 

mechanism of the spasmodic respiratory symp- 
toms of hysteria is entirely subconscious, and, 
therefore, these manifestations are not pro- 
duced by conscious efforts, nor are they de- 
pendent upon conscious impulsions. Instead 
of being ashamed the patient ignores her respi- 
ratory tics ; she may be even unaware of them. 

Abnormally frequent sighing and yawning 
is often seen in cases of hysteria, but these 
symptoms are comparatively unimportant. 
Several times a year the dispensaries of large 
hospitals receive patients who present contin- 
ued singultus vera. By means of the news- 
papers these cases may be traced from one dis- 
pensary to another until, after several days, 
weeks, or months, the symptom disappears. In 
spite of various kinds of treatments in different 
hospitals, hiccough had continued to occur 
about every thirty seconds in one of my cases. 
By means of hypnotic suggestion the symptom 
was immediately removed. 

Attacks of sneezing and of rhinorrhoea some- 
times appear during emotional excitement. In 
one instance I have known a young lady by 
psychic contagion alone to contract such at- 
tacks from her sister. When sufficiently elab- 
orated these attacks constitute what cannot 
be differentiated from the syndrome known as 
hay fever. Suppose an acute rhinitis with 
sneezing is acquired by an individual at a time 
of the year when ordinary colds are uncommon 



Visceral and Circulatory Derangements 139 

— when hay fever is in season. More than one 
kind friend may express sympathy while in- 
forming the patient that the condition is hay 
fever, and that it will return at the same time 
every year. This suggestive explanation is apt 
to be accepted, especially by one who obviously 
is hysteric, with the consequence that the 
individual begins to anticipate his "hay fever' ' 
at about the same time the following year. Now, 
if this state of expectant attention is sufficiently 
developed to produce recurrence of the symp- 
toms of what originally was an ordinary cold, 
then a precedent is established, an association 
neurosis is formed, and each recurrence only 
strengthens the primarily weak associations 
just as any habit becomes more fixed as the 
result of repeated indulgence. 

Morton Prince has reported an instance of 
"hay fever " existing as a neurosis in five mem- 
bers of one family. One of these patients was 
told by a physician that fruit was capable of 
inducing • attacks. Subsequently, she was 
unable to eat fruit without suffering from hay 
fever. The evident influence of autosuggestion 
in the production of hay fever caused Prince 
to propound the question: "May not a very 
large number — one cannot generalize too ex- 
tensively and say all — of the cases of recurrent 
periodic hay fever develop in the same way? 
May not the attacks come on at a certain date 
because of apprehension or expectancy, by 



140 Psychopathology of Hysteria 

which the patient suggests to himself or her- 
self that at that time he or she will be suscep- 
tible to external irritants of one kind or an- 
other, and then at the suggested time the irri- 
tant produces its habitual and expected ef- 
fect?" (Annals of Gynaecology and Paediatry, 
1895). 

How often we encounter patients who declare 
that their hay fever will begin on a certain 
date, — that such always has been the case ! Be- 
cause change of environment is reputed to be 
effectual in warding off recurrences of hay fever, 
and because they know from experience that such 
often has been the case, these patients, if their 
position in life enables them to do so, will com- 
mence long in advance of the set date to arrange 
their affairs so that they can escape to their 
favorite retreat just before the attack is due. In 
a case of hysteria such a state of mind certainly 
is most favorable for the induction of what is 
expected so confidently; either the appearance 
of an attack about the time it is expected, or 
the avoidance of one resulting from the pa- 
tient's conviction relative to the prophylactic 
effects of a prospective vacation. Concerning 
the yearly recurrence of attacks on a fixed date, 
Prince questions the pathogenic influence, other 
than through the agency of expectancy, of the 
relative position of the moon to the earth. 

That many, at least, of the cases of what 
clinically is known as hay fever are really symp- 



Visceral and Circulatory Derangements 141 

toms of hysteria is shown by the fact that we 
can cure many of these cases by no other means 
than suggestion. On the other hand, Prince 
has been able to produce coryza by means of de- 
liberate post hypnotic suggestion. Having sug- 
gested during hypnosis to "B. C. A." that the 
presence of a certain flower caused hay fever 
subsequently she developed coryza when exposed 
to this flower, even though she had never had 
hay fever, or thought about it, before the sug- 
gestion had been made. After having been 
awakened she did not remember the suggestion, 
and when the coryza appeared the thought 
flashed into her mind that if it were summer she 
would think she had hay fever. ( The Mechanism 
of Recurrent Psychopathic States, with Special 
Reference to Anxiety States, Jour, of Abnormal 
Psychology, Vol. 6, p. 148.) 

It seems that hysteria is capable of causing 
what cannot be differentiated from asthma, as 
far as symptoms and clinical signs are concerned. 
As a matter of fact, many cases of psychogenic 
asthma have been reported, and the cure of such 
cases through the agency of hypnotic suggestion 
is ample proof of the validity of the diagnosis. 

For nine years, Mr. X., an individual whose 
manifestations were those of hysteria and who 
also presented psychasthenic fears, had been 
afflicted with frequently recurring attacks which 
were typical of asthma. The seizures first ap- 
peared during an attack of influenza, and they 



142 Psychopathology of Hysteria 

recurred every morning at about three o'clock. 
Examination of his chest revealed the typical 
signs that one would expect to find in a case of 
asthma of nine years duration. Since the first 
treatment with hypnotic suggestion the patient 
has not had a single attack of asthma. (Report 
of a Case of Dissociated Personality, Jour, of 
Abnormal Psychology, Aug.-Sept., 1909.) 

Before the true nature of the condition was 
recognized another patient had been treated in 
a hospital a whole week for cardiac asthma. 
The attacks occurred several times daily and 
each lasted about a half hour. One appeared 
during his visit to the dispensary. Following 
a sudden deep inspiration, rapid stertorous 
respiration developed, the face became cyan- 
otic, and lachrymation occurred. After about 
a half minute the neck became extended and 
rigid, the hands tightly clenched, the limbs 
catatonic, and the pupils widely dilated. This 
phase of the seizure lasted about two minutes, 
and then he relaxed, and dyspnoea continued in 
association with a succession of brief attacks 
whose main features were general but moderate 
clonic movements and a state of consciousness 
resembling the somnambulistic states of hys- 
teria or of hypnosis. That the attacks were 
due to hysteria was indubitable. As the pa- 
tient did not return — he lived at some distance 
from the city — the outcome of the treatment 
is not known. 



Visceral and Circulatory Derangements 143 

A third patient, aet. 23, had suffered from 
asthma since an attack of pertussis in his 
eighth year. Severe asthmatic seizures which 
lasted over 48 hours occurred about once 
monthly. These were so severe that he was 
totally incapacitated for three or four days, 
and, on account of losing so much time from 
his work, he was about to be discharged from 
his place of employment. Each of the major 
attacks was preceded for 24 hours by decided 
aggravation of his bronchial symptoms. In no 
way did his seizures differ from what is typical 
asthma, and not any of the physicians who had 
examined him had questioned the diagnosis. 
In addition to the severe attacks, he was sub- 
ject to lesser ones which occurred twice every 
night and which lasted about three-quarters of 
an hour. These mild ones were prone to arouse 
him at two and at five-thirty in the morning. 
The physical signs were those characteristic of 
well developed asthma; namely, the physical 
signs of chronic bronchitis and emphysema. 

The treatment consisted entirely of hypnotic 
suggestion. The first treatment was given 
while the patient was having one of his severe 
attacks. Immediately upon the induction of 
hypnosis his respiration became decidedly less 
difficult. During the following 24 hours his 
symptoms, though very distressing, were much 
less severe than usual. Extending over a 
period of four months he was hypnotized seven 



144 Psychopathology of Hysteria 

times with the following results: After the 
first treatment he did not have a single severe 
attack, and the milder ones progressively im- 
proved until they, too, entirely disappeared 
after the sixth treatment. 

Alimentary System. The experiments of 
Pawlow, Cannon, and others have shown the 
great importance of the effects of appetite and 
of emotions upon the secretion of gastric juice. 
The experiments of Pawlow, (The Work of the 
Digestive Glands, 1910,) for instance, showed 
that the mere exhibition of food to a dog re- 
sulted in the secretion of gastric juice in quan- 
tities which actually exceeded those provoked 
by allowing the dog to swallow the same food 
and to eject it through an oesophageal fistula. 
It was observed, also, that the quantity of 
juice secreted largely depended upon the in- 
tensity of the desire for food, so that the author 
says emphatically: " Appetite spells gastric 
juice." The truth of this dictum was unques- 
tionably demonstrated by the fact that though 
the sight of food induced almost immediate 
and copious secretion of gastric juice, yet, pro- 
viding only that the animal was unaware of 
the presence of food, the direct introduction of 
food through a gastric fistula was followed by 
the secretion of a greatly inferior quantity of 
the juice, and the appearance of this secretion 
was delayed for one-half to several hours. 



Visceral and Circulatory Derangements 145 

Depressing emotions not only cause an un- 
pleasant dryness of the mouth but they are 
capable- also of inhibiting gastric secretion. 
Moreover, the digestive juices are not secreted 
in sufficient quantities when one eats without 
experiencing desire for food, or when there is 
positive distaste for food. As a secondary pro- 
cess fermentation occurs, followed by auto-in- 
toxication and anorexia — a vicious circle is 
formed. 

In most of the cases of gastric neurosis the 
patient, possessing an elaborate system of 
erroneous ideas concerning digestion, believes 
that he has some organic gastric disease. Con- 
stantly being obsessed by the fear that through 
some dietary indiscretion he will aggravate his 
existing dyspepsia the flow of digestive juices 
is rendered insufficient as a result of his de- 
pressing mental states during meals. This type 
of gastric neurosis, or "emotional dyspepsia," 
may be classified as a manifestation of psychas- 
thenia. Less frequently the condition occurs 
in hysteria. In this case the imperfect secre- 
tion of the digestive juices is due to absence of 
appetite — psychic anorexia — ; the patient eating 
in order to avoid the importunities of the 
family. Or, attacks of indigestion may follow 
undue emotional activity. 

The following instance, mentioned by W. B. 
Cannon, well illustrates the disturbing effects 
of emotional excitement upon digestion: "A 



146 Psychopathology of Hysteria 

refined and sensitive woman who had had 
digestive difficulties, came with her husband to 
Boston to be examined. The next morning the 
woman appeared at the consultant's office an 
hour after having eaten a test meal. An ex- 
amination of the gastric contents revealed no 
free acid, no digestion of the breakfast, and 
the presence of a considerable amount of the 
supper of the previous evening. The explana- 
tion of this stasis of the food in the stomach 
came from the family doctor, who reported that 
the husband had made the visit to the city an 
occasion for becoming uncontrollably drunk, 
and that he had by his escapades given his wife 
a night of turbulent anxiety. The second 
morning, after the woman had had a good rest, 
the gastric contents were again examined; the 
proper acidity was found, and the test break- 
fast had been normally digested and dis- 
charged. ' ' ( Amer. Jour, of the Med. Sci. Apr. 
1909.) 

Anorexia. The most grave of the symp- 
toms of hysteria is anorexia; a condition which 
only too frequently has eventuated in death. 
Since the introduction of rectal alimentation and 
the stomach tube death from hysteric anorexia 
would seem to be unpardonable. The anorexia 
has been ascribed to visceral anaesthesia, but it 
should be remembered that this anaesthesia, like 
the other varieties, must, be only subjective ; the 
condition being the result of lack of synthesis 



Visceral and Circulatory Derangements 147 

with consciousness of the perceptions of coenes- 
thetic impressions pertaining to the feeling of 
hunger — the feeling of need for food. The 
stomach is not the only factor concerned in the 
feeling of hunger, and, therefore, a hypothetical 
gastric anaesthesia does not explain hysteric 
anorexia. If an ecstatic is firmly convinced that 
she can live without eating, if she believes that 
she is the instrument of a miracle, complete dis- 
sociation can occur of all the perceptions con- 
cerned in the composition of the feeling of hun- 
ger, just as Miss Beauchamp developed systema- 
tized lack of perception of auditory, tactile, and 
visual impressions arising from the rings which 
she thought she had lost. 

The origin of this peculiar and dangerous 
symptom may have been some former event 
which was prominently associated with eating, 
or the idea of hunger, and which made a strong 
impression upon the patient's mind. Or it may 
have been the result of hysteric elaboration and 
fixation of a purely symptomatic and transient 
distaste for food. In some cases the symptom 
is the direct outcome of too careful dieting, by 
physicians, of patients with hysteric disturbances 
of digestion; the patient gradually eliminating 
from her diet one kind of food after another, 
as the feeling of the need for food gradually is 
dissociated. Regardless of the cause, the patient 
refuses to eat because there is an absolute lack 
of desire for food, even though there is not any 



148 Psychopathology of Hysteria 

real disturbance of the digestive system, and in 
spite of the fact that emaciation progresses 
rapidly. Janet describes a case whose anorexia 
was dependent upon hallucinatory commands 
from her dead mother, who, reproaching her 
for some faults she had committed, told her that 
she was not worthy to live, and that by refusing 
to eat she should rejoin her in heaven. (Mental 
State of Hystericals, p. 288.) 

In addition to true psychic anorexia hysteric 
individuals may simulate the condition in order 
to attract attention to themselves and to excite 
wonder. In such cases the patient affirms that 
she can live without eating, or that she cannot 
eat because she has no desire for food; yet 
emaciation does not ensue because privately 
she is consuming a sufficient amount of food. 
Notwithstanding the fact that the condition is 
simulated the patient cannot be called a 
malingerer with any greater justice than one 
can apply the same designation to an insane 
patient who simulates certain of his manifesta- 
tions in consequence of motives which, them- 
selves, are symptoms of insanity. 

As these cases of simulated anorexia or fast- 
ing usually occur in hysterics, the patient, if 
prevented from secretly obtaining nourishment, 
may starve herself to death rather than ac- 
knowledge the deception which she has prac- 
ticed. Hammond made a collection of cases of 
simulated fasting, and in one instance — Sarah 



Visceral and Circulatory Derangements 149 

Jacob — to the disgrace of all those concerned, 
including a vicar, nurses, and physicians, the 
patient was forced to starve herself to death 
because the careful guarding by nurses that 
had been sent from Guy's Hospital finally pre- 
vented any further eating in private. In the 
interest of science and truth, then, a hysteric 
girl was forced to commit suicide. Those who 
were responsible for the fatal outcome escaped 
serious consequences, except the patient's 
father and mother, who were committed to jail 
for 12 and 6 months respectively. (Nervous 
Derangement 1883, p. 95.) 

The anorexias of hysteria should not be con- 
founded with those of psychasthenia. The 
psychasthenic refuses to eat not because he 
lacks desire for food, but principally through 
fear of the gastric distress, or other suffering, 
that he knows will surely follow. This 
emotional dyspepsia of expectancy and fear 
constitutes the very common gastric neurosis 
in whose production the physician is the main 
factor by reason of his paying too much atten- 
tion to the organs of digestion instead of to the 
patient. 

Vomiting. Hysteric vomiting, another serious 
manifestation which has been known to ter- 
minate in death, and which usually occurs 
in association with hysteric anorexia, is not at 
all uncommon. Generally its origin is found to 
be some former acute disease which occasioned 



150 Psychopathology of Hysteria 

vomiting, and, after the original cause sub- 
sided, the symptom continued as a manifes- 
tation of hysteria. By reason, too, of ex- 
pectant attention, or what really is unconscious 
autosuggestion, the physiological vomiting of 
pregnancy can be caused to persist. 

Just as the normal person may experience 
nausea, and even vomiting, as a concomitant of 
disgust, so the hysteric may suffer from hyper- 
emesis as a result of subconscious ideation. It 
is well known that association of ideas is ca- 
pable of producing vomiting. A typical instance 
is mentioned by Carpenter: "Thus Van 
Swieten relates of himself, that, having chanced 
to pass a spot where the bursting of the dead 
body of a dog produced such a stench as made 
him vomit, on passing the same spot some years 
afterwards he was so vividly affected by the 
recollection, that the sickness and even vomit- 
ing recurred." (Mental Physiology, p. 432, 
1883.) If Van Swieten had forgotten the 
original disgusting experience with the conse- 
quence that each time he vomited he had been 
ignorant of its cause, then his case would be 
identical with the mechanism of production — 
subconscious association of ideas — of symp- 
toms of hysteria. As it was it resembled psy- 
chasthenia in that the symptoms were the effect 
of conscious association of ideas. 

The hysteric, then, may vomit whenever there 
is aroused into activity, by association of ideas, 



Visceral and Circulatory Derangements 151 

a dissociated complex of memories of some for- 
mer experience which made a distinct impres- 
sion upon the patient, and in which vomiting 
was a prominent factor. As the provocative 
association of ideas usually occurs below the 
level of consciousness, it is only by some psy- 
choanalytic method that the origin of the con- 
dition can be discovered. Motor activity of this 
sort, whether it is a convulsion, a contracture, 
a tremor, vomiting or what not, constitutes 
what is termed motor automotism; a condition 
characterized by motor activity independently 
of consciousness; a dissociation of motor ac- 
tivity. 

In treating a case of alcoholism with hypnotic 
suggestion we may artificially create a motor 
automatism whose psychic mechanism is identi- 
cal with that of hysteria. While the patient is 
in the hypnotic state suggestions are made that 
tend to strengthen his moral character; which 
are directed against the fundamental neurosis; 
ones which are calculated to abolish the crav- 
ing. Then we may suggest that the idea of drink- 
ing liquor will always be associated with a feel- 
ing of disgust, that the odor alone will nauseate 
him, and that if he should ever take any alco- 
holic drink he would vomit immediately. If 
the patient is a good hypnotic subject he will 
not remember any of these suggestions after 
the hypnotic state is dispelled. In this manner 
we have produced a dissociated memory com- 



152 Psychopathology of Hysteria 

plex which, when aroused into activity by the 
proper stimulus, should produce vomiting. 
Now, if at any time the patient should take 
some whiskey he would probably vomit, and, 
like the hysteric, he would not know the real 
cause of his vomiting — the association of ideas 
would be subconscious. 

Often the vomitus contains blood, and then 
the diagnosis becomes difficult indeed. If we 
accept the possibility of vasomotor disturb- 
ances due to the disease, then true hysteric 
haematemesis can occur just as other haemor- 
rhagic conditions have been known to be pro- 
duced both by hysteria and by hypnotic sug- 
gestion. Excepting this possibility, one which 
is the subject of much controversy and which 
must be extremely infrequent, all cases of 
hysteric haematemesis are merely instances of 
deception: as far at least, as the presence of 
blood in the vomitus is concerned. At all 
events, in each of the few cases which have 
come under my observation the patient had 
swallowed blood procured by picking at the 
nostrils until epistaxis was produced. 

Even though a patient with hysteric vomit- 
ing deliberately simulates haematemesis such 
deception cannot be regarded other than as a 
manifestation of a pathologic mental state. 
With no other object than to gain sympathy 
certainly no normal persons would carry the 
deception so far as to seek, and to undergo, 



Visceral and Circulatory Derangements 153 

operations for supposed gastric ulcer. This 
type of deception is malingering only to the 
same extent as that of cases of hysteria in 
which simulated anorexia has terminated in 
death. > Surely, malingering for the purpose of 
exciting sympathy, or wonder, is as much a 
symptom of hysteria as a psychic hemiplegia 
or a psychic amaurosis. 

The differential diagnosis in cases of hysteria 
presenting haematemesis is extremely difficult. 
Only those who have had cause to worry much 
about cases of hysteria whose symptoms in- 
cluded anorexia, vomiting, localized epigastric 
pain, tenderness, and perhaps haematemesis, 
can appreciate just how difficult the diagnostic 
problem may become. Even if haematemesis 
appears in a patient who is known to be a 
major hysteric, one may not jump at conclu- 
sions and dismiss the question of gastric ulcer 
with the inference that the condition is "only 
hysterical." In some cases the physician must 
treat the patient as though the symptoms were 
due to gastric ulcer, notwithstanding that he 
may surmise them to be but manifestations of 
hysteria and knowing that if this be the case 
his treatment, even if successful as far as the 
present symptoms are concerned, is almost sure 
to aggravate the fundamental psychopathic 
state. 

A problem that infrequently may confront 
the surgeon is due to hysteric reproduction of 



154 Psychopathology of Hysteria 

the symptoms of bowel obstruction. In addi- 
tion to obstinate constipation, abdominal dis- 
tention, pain and vomiting, the patient may 
develop faecal vomiting. In some cases rectal 
injections of various fluids, including castor 
oil, have been followed in from 12 to 15 min- 
utes by expulsion of the injected substance 
from the mouth. 

Aerophagia. Swallowing of air frequently 
occurs as a symptom of hysteria. As a con- 
sequence of the distress which is occasioned 
the patient voluntarily belches at frequent in- 
tervals. Ordinarily an eructation occurs more 
or less spontaneously; otherwise it must be 
initiated by gulping of air. The aerophagic is 
the victim of a vicious circle: she belches in 
order to relieve her gastric distress, and with 
each eructation she swallows more air. 

In case the ingested air is forced through the 
pylorus meteorism develops. The old theory 
that attributed meteorism to paresis of the in- 
testinal muscles with consequent expansion of 
the gaseous contents of the bowels, is not in ac- 
cordance with the fact that usually the condi- 
tion disappears when the patient is anaesthetized. 
Instead of causing meteorism to vanish the mus- 
cular relaxation which is induced by ether or 
chloroform anaesthesia should permit further 
abdominal distention were the condition due to 
intestinal paresis. 

When abdominal distention is produced by 



Visceral and Circulatory Derangements 155 

spasm of the diaphragm the distention cannot 
be as great as that due to asrophagia. It is this 
spastic type which disappears during general 
anaesthesia, and, as shown by Janet, during 
laughter, sobbing, and hiccoughing — phenomena 
which are dependent upon normal activity of the 
diaphragm. By means of radiographic examina- 
tions Bernheim found that the diaphragm is low- 
ered daring meteorism, and that as the abdomi- 
nal distention is diminished through the agency 
of suggestion the diaphragm gradually ascends 
and commences to take part in the function 
of respiration. (Hypnotisme & Suggestion, 
1910, p. 380.) 

Meteorism may lead to enormous distention of 
the abdomen. The enlargement may be gradual 
and associated with symptoms of pregnancy, so 
that in not a few cases of pseudocyesis physicians 
have been deceived until labor should have com- 
menced. The production of simple amenorrhoea 
by expectancy and fear is quite common, and 
this effect of vaso motor disturbance is much 
more remarkable than any of the other symp- 
toms which enter into the make up of pseudocye- 
sis. The symptoms are due to the patient's con- 
viction that pregnancy exists, and, needless to 
say, this belief may be born either of great de- 
sire for a child, or of intense fear of becoming 
pregnant. Preston mentions the ludicrous 
case of a girl who believed herself to be preg- 
nant as a result of masturbation and whose abdo- 



156 Psychopathology of Hysteria 

men was moderately distended. (Hysteria and 
AUied Conditions, 1897, p. 181.) 

Wesley Taylor describes a case of hysteric 
aerophagia in which the abdomen was distended 
to a degree greater than that of pregnancy at 
the ninth month. The meteorism of this patient, 
a girl of twenty years, occurred paroxysmally, 
and during the height of one of the attacks, the 
condition somewhat resembled general periton- 
itis. The attacks appeared as often as every 
two weeks and lasted as long as ten days or 
more. The interesting feature of the case was 
the fact that once she had been subjected to 
an operation and, on another occasion, she es- 
caped a second one only because of the rapid 
disappearance of the distention during etheriza- 
tion. (Jour. -Record of Med., 1909, p. 74.) 

In addition to general gaseous distention of 
the abdomen localized tumor like masses have 
been known to occur in hysteria. These phan- 
tom tumors, whether due to localized collections 
of gas in the intestines or to isolated muscular 
contraction in the abdominal wall, have been 
mistaken for real tumors, and even operations 
have been performed to the chagrin of the sur- 
geon. 

The appetite of the hysteric is capricious. 
In addition to craving unusual articles of diet 
she may ingest such substances as plaster and 
hair. Including his own case, Butterworth 
collected from the literature 42 cases of hair 



Visceral and Circulatory Derangements 157 

ball of the stomach. Of these patients 39 were 
females. The largest hair cast weighed about 
six pounds. The final results of 33 cases com- 
prised 17 laparotomies with one death. 6 deaths 
from peritonitis and perforation, and 10 deaths 
from inanition. Thus the outcome was fatal in 
over half of the cases in which this was known. 
The correct diagnosis was made before opera- 
tion in only five instances. (Jour, of the A. M. 
A.. 1909, 2, 617.) 

It is difficult to conceive the possibility of 
the production by hysteria of symptoms capable 
of being mistaken for acute appendicitis, yet 
such is not rare. Twenty cases of hysteric 
pseudo-appendicitis were compiled by Karl 
Urband. A patient of his own developed 
acutely localized pain and rigidity, associated 
with slight abdominal distention, vomiting, 
superficial respiration, temperature 99% and 
pulse 72. Subsequently these symptoms sub- 
sided, but several weeks later, following a chill, 
the temperature rose to 104% and the pulse to 
144 only to fall again to normal the next day. 
After twelve more days he had another chill 
and similar rise in temperature in addition to 
severe pain in the region of the appendix. At 
operation the appendix was found to be nor- 
mal. (Wiener Med. Woch., 1908. p. 1918.) 

Every one of the usual symptoms of acute 
appendicitis, including moderate rise of tem- 
perature, was reproduced by a major hysteric 



158 Psychopathology of Hysteria 

who came under my own observation. The 
elimination of appendicitis was accomplished 
only by the discovery of two significant fea- 
tures: during the painful reaction produced 
by deep pressure over McBurney's point the 
patient's respiration became deeper than usual, 
and when the pressure was exerted while the 
patient's attention was distracted both the 
rigidity and the painful reaction were found 
to be absent. 

Prolonged attacks of diarrhoea or of obsti- 
nate constipation are common. More impor- 
tant is the occurrence of what is called mucus, 
or membranous, entero-colitis. "Whether this 
condition be looked upon as a symptom of 
hysteria or as an independent clinical entity, 
the fact remains that it is said to occur only 
in psychoneurotic persons. The affection is- 
characterized by attacks of severe abdominal 
pain that may last several days or longer and 
which are associated with, or are followed by, 
the presence in the stools of considerable mucus, 
and even blood; the patient perhaps being free 
from abdominal symptoms in the intervals be- 
tween attacks. When the mucus is passed in 
the form of tubular casts that present the 
appearance of membranes, the condition is 
called membranous entero-colitis. Either of 
these abdominal crises may recur for many 
years, apparently without being influenced by* 
treatment. 



Visceral and Circulatory Derangements 159 

A patient who presented an admixture of 
symptoms of hysteria and of psychasthenia for 
years had been subject to severe attacks which 
usually followed undue excitement, and which 
occurred several times a month. During the 
crises her stools were extremely offensive and 
consisted largely of mucus mixed, at times, 
with blood. Rarely casts were passed. While 
she was travelling in Germany some intra- 
abdominal operation was performed during one 
of the attacks, but subsequently recurrences 
took place as before. Much to my surprise the 
attacks ceased to appear shortly after the adop- 
tion of treatment with hypnotic suggestion 
which was directed mainly against the asso- 
ciated symptoms. 

The different abdominal syndromes resulting 
from hysteria are most resistent to treatment, 
and each may appear, continue indefinitely, and 
then disappear suddenly without apparently 
having been influenced at all by any of the 
therapeutic measures that had been adopted. 

Genito-Urestary Derangements. Increased 
frequency of urination often occurs in hysteria, 
but more commonly this symptom is caused 
by a psychasthenic fear that the necessity to 
urinate will appear at a time when social con- 
siderations would render the act impossible; 
the patient urinates, therefore, at frequent 
intervals in order to avoid such embarass- 
ment, and, when the fear is well developed, 



160 Psychopatkology of Hysteria 

he may refrain even from going to places 
of amusement or to social events. In such 
cases the fear results from conscious associa- 
tion of ideas with the memory complex of 
some former experience when distress was 
caused by actual necessity to urinate at a time 
when the circumstances were such that the act 
was impossible. In hysteria, on the other 
hand, the urinary frequency is not associated 
with fear, and the underlying association of 
ideas is not consciously known. Further to 
differentiate the two conditions one might say 
that the psychasthenic urinates too frequently 
in order that he may be in a position the longer 
to hold his urine should this be required, while 
the hysteric variety is due to unconscious auto- 
suggestion, and the act of micturition occurs 
regardless of thoughts of future environment. 
In psychasthenia the condition is the result of 
an obsession; in hysteria it is due to what is 
termed a sensory automatism. As a conse- 
quence of subconscious ideation the hysteric is 
subject to hallucinations of imperative sensory 
impressions from the bladder. 

Polyuria occurs frequently at the termina- 
tion of hysteric seizures, and, less often, an 
increased amount of urine may be passed daily 
for long periods of time independently of crises 
and without discoverable cause other than hys- 
teria. 

That complete anuria lasting several days 



Visceral and Circulatory Derangements 161 

can occur as a symptom of hysteria has been 
the subject of much dispute, but more than one 
case has been recorded in which deception 
could be eliminated. Less infrequently the 
daily amount of urine voided has been reduced 
to a few ounces, or less, and the deficiency has 
continued for days or weeks at a time. In 
either case the absence of urasmia is explained 
by the fact that in these patients anuria is 
compensated by profuse sweating, vomiting, 
or diarrhoea. Frequently patients are encoun- 
tered who maintain either that they do not pass 
any urine at all, or that the amount has been 
reduced to a few spoonsful, yet, when kept 
under supervision, or if catheterized, the re- 
sults show that deception is being practiced. 

The majority of cases of hysteric retention 
of urine are due to the continuation produced 
by autosuggestion, of the common but tem- 
porary post-operative retention. In such cases 
the longer catheterization is continued the 
longer it will be necessary, so that strenuous 
means should be adopted to cause the patient 
normally to urinate soon after operations have 
been performed. Retention often is simulated, 
and, like anuria, the deception can be exposed 
by catheterization and close observation. 

Quite the reverse of the ordinary conceptions 
of the sexual instinct in hysteria is the actual 
state of the genital function. Taking into con- 
sideration the vast numbers of hysterics, rarely, 



162 Psychopathology of Hysteria 

indeed, does the disease produce inordinate 
desire and gratification. Less infrequently the 
sexual instinct manifests itself by symbolic 
mental activity, or by conversion into the physi- 
cal manifestations of hysteria. Usually the 
patient not only loses whatever sexual desire 
she may have possessed, but sexual intercourse 
becomes repugnant. It is not at all uncommon 
for patients to remark that since they became 
nervous they have been sexually indifferent, 
whereas the opposite formerly was the case 
with them. It is true, however, that excluding 
those cases due to cultivation, degeneration, 
and insanity, the majority of sexual perverts 
owe their perverse inclinations to associations 
of ideas which were usually originated in early 
life. A number of cases have been subjected 
to psycho-analysis and the reports have been 
most instructive, both in accounting for con- 
ditions which heretofore have been erroneously 
grasped, and in adducing further corroboration 
of the theory of submerged complexes as the 
underlying psychic mechanism of the psycho- 
neuroses. 

In addition to other manifestations of hys- 
teria and of psychasthenia a patient who was 
studied by Sidis was obsessed with ideas of 
homosexual relations. Hypnoidal psycho- 
analysis brought out the fact that when the 
patient was in his eighth year some older 
schoolmates had forcibly violated him. Having 



Visceral and Circulatory Derangements 163 

informed his parents of the fact he was removed 
from the school. "This experience lapsed from 
his conscious memory, but remained firmly im- 
planted on his subconscious memory, giving 
rise to the apparently unaccountable homo- 
sexual ideas at which he felt so much disgust. 
The homo-sexual ideas were really foreign to 
his character and no wonder his whole nature 
felt revolting disgust towards them." (Studies 
in Psychopathology, Boston Med. and Surg. 
Jour., Mar. 14 to Apr. 11, 1907.) 

According to the nature of the perversion 
itself, and according to the character of asso- 
ciated symptoms, the patients may be classi- 
fied either as hysterics or as psychasthen- 
ics. When the perverse ideation or actual 
gratification is dependent upon obsessions 
against which the patient strives in vain the 
condition may be designated psychasthenic. 
Besides the instance just mentioned the Rev. 
A. Kampmeier's case illustrates the character 
of psychasthenic deviations of the sexual in- 
stinct. After reading a book which dealt with 
the evil consequences of sexual irregularities 
the patient "became very chaste from fear of 
the horrible consequences of a lapse from vir- 
tue." Obsessions having developed from the 
material afforded by the well-meant but de- 
cidedly pernicious book, the patient suffered 
much psychic distress and then, as he expresses 
the outcome: "My demon finally drove me to 



164 Psychopathology of Hysteria 

make true what I imagined would inevitably 
come about had I not read that book. I gave 
myself up to sexual excesses, not for the pleas- 
ure of them, since in my case this was impos- 
ible, but to make true what I thought would 
have been my fate." (Confessions of a Psych- 
asthenic, Jour, of Abnormal Psych., vol. 2, 
p. 112.) 

As a slight amount of distress in the ovarian 
regions may be considered a concomitant of 
normal menstruation it is just as natural for 
this normal symptom to become elaborated and 
fixed by autosuggestion as it is for a sympto- 
matic anesthesia or paralysis to become fixed 
in a similar manner. Therefore, in most female 
hysterics a suitable foundation is commonly at 
hand for the development of psychic pains in 
the ovarian regions. It is unusual for a lap- 
arotomy to show that both ovaries are entirely 
free from lesions, negligible or otherwise, and, 
following the removal of one or both ovaries, 
the pain is very apt to disappear as the result 
of the powerful suggestive effects of an opera- 
tion. These facts account for the former dis- 
graceful popularity of oophorectomy. Possible 
suggestive effects being insufficient justifica- 
tion, gynecologic operations should never be 
performed on a hysteric unless the same pro- 
cedures positively would be indicated in the 
absence of hysteria. 

In reference to the relation between the 



Visceral and Circulatory Derangements 165 

psychoneuroses and the pelvic viscera the re- 
sults of Clara T. Dercum's statistical analysis 
of 591 gyngecologic patients are most interest- 
ing. "The above tables," she concludes, 
"speak for themselves; there is obviously no 
relation between hysterical stigmata and pelvic 
disease; this is likewise true of the symptoms 
of neurasthenia. That hysteria and neuras- 
thenia can coexist with pelvic disease goes 
without saying, just as they may coexist with 
a brain tumor or a broken leg. The above 
statistics do not even show that neurasthenia 
or hysteria exist as frequently in pelvic dis- 
eases as in other visceral affections. Certainly 
the above facts prove that operations on the 
pelvic and other viscera for the relief of ner- 
vous symptoms have no justification. It is per- 
fectly clear that no operation should be per- 
formed which has no positive surgical indica- 
tions. When this subject is fully understood 
the fastening up of so-called loose kidneys, the 
removal of normal ovaries and tubes, of normal 
uteri, of normal appendices, of pieces of normal 
coccygeal bone, will cease, as will also repair of 
trivial cervical lacerations. A careful exam- 
ination of the records from hospital labora- 
tories will abundantly testify to this assertion 
of the removal of normal organs." (Jour, of 
the A. M. A., March 13, 1909, p. 848.) 

Circulatory and Trophic Phenomena. 
Cardiac neuroses seldom are found in hysteria; 



166 Psychopathology of Hysteria 

these conditions being part of the symptom- 
atology of psychasthenia. Increased frequency 
of the cardiac rate accompanies hysteric crises 
for the reason that it is a normal concomitant 
of emotional excitement or a normal consequence 
of muscular effort. Less easily understood are 
some of the vasomotor and trophic manifestations 
which seem rarely to occur as symptoms of hys- 
teria, and whose origin in this manner is denied 
by many. Sudden flushing of the face, coldness, 
and even local asphyxia, are ordinary symptoms. 
The effect of the mind upon the vasomotor func- 
tion is apparent in the anaesthesias both of hys- 
teria and of hypnosis in that it is difficult some- 
times to obtain a free capillary flow of blood 
from anaesthetic regions. More remarkable are 
the rare instances of spontaneous capillary 
haemorrhage that occurred in the so-called stig- 
matics. Of these the best known is Louise 
Lateau; a typical hysteric in whom haemor- 
rhages mainly from the hands, feet, fore- 
head and left side of the chest appeared every 
Friday during a state of ecstasy in which she 
acted the crucifixion. The haemorrhages took 
place even though an apparatus was applied 
for the purpose of preventing deception. Ac- 
cording to Dr. Lefebvre about % of a quart of 
blood was lost each time the haemorrhages oc- 
curred. Physicians who studied the case came 
to the conclusion that the phenomena resulted 
from autosuggestion. With hypnotic sugges- 



Visceral and Circulatory Derangements 167 

tion Bourru and Burot, and Mabille succeeded 
in producing similar manifestations. 

Hysteric purpura is an uncommon condition. 
While examining a hysteric more than a dozen 
purpuric spots varying in size from % to 3 
inches in diameter were found in various parts 
of her body, yet she had not known that a 
physical examination was to be made and she 
denied having been injured in any way. Her 
blood was found to be normal. The purpuric 
areas did not disappear for more than two 
weeks. 

Circumscribed oedema may develop acutely 
or slowly, and, after lasting an indefinite length 
of time, it may disappear just as suddenly or 
gradually. The lesion is white or bluish and 
pits but little under pressure. When occurring 
about joints — especially when associated with 
pain and paresis — the condition may be mis- 
taken for arthritis. What has been termed 
hydrops articulorum intermittens is similar to 
the oedema of hysteria, and it occurs most fre- 
quently in the functional neuroses. As defined 
by W. Healy it is: "A chronic affection char- 
acterized by an effusion poured out into one 
or rarely more joints, at regular or irregular 
intervals, without any ascertainable exciting 
cause for the recurrence, and without any per- 
ceptible anatomic alteration as cause or result 
of the repeated attacks." (Surg. Gyn., and 
Obstet., 1908, p. 466.) The nature of the con- 



168 Psychopathology of Hysteria 

dition is indicated by the fact that psychic in- 
fluences are capable of inducing attacks, abort- 
ing them, and even in curing the disease. 
The possibility that some of the symptoms of 
hysteria may result from localized areas of 
angioneurotic oedema in the brain has been sug- 
gested tentatively by G. L. Walton. (Internat. 
Clinics, vol. 3, series 18, p. 242.) 

Hysteric gangrene is another of the mani- 
festations which is subject to controversy; not 
only because of the difficulty in explaining its 
mechanism, but also because of the frequency 
with which the lesions are the product of de- 
ception. Thus, Dieulafoy's patient, a male hys- 
teric, by chemical irritation caused multiple re- 
curring gangrene which was diagnosed trophic 
ulceration by a surgeon who amputated one of 
the patient's arms because of the continued re- 
currence of the lesions. (La Presse Medicale, 
1908, p. 369.) 

There are numerous instances on record of 
the successful production, by means of hypnotic 
suggestion, of dermographia, inflammation, 
bullae, ulceration, and gangrene. Many of these 
experiments were conducted under conditions 
which precluded the possibility of deception. 
By means of the application of objects with the 
suggestion that they were hot, it was possible 
with lima S. to cause skin lesions varying from 
simple redness to actual ulceration. These 
reactions were obtained even when the parts 



Visceral and Circulatory Derangements 169 

were carefully bandaged and sealed. (An 
Experimental Study in the Domain of Hypnot- 
ism, by Von Krafft-Ebing, Chaddock trans., 
1896.) 

Beaunis described some interesting experi- 
ments which were performed by Focachon in 
the presence of Bernheim, Liebault, and him- 
self. Postage stamps having been applied to 
the subject's back with the suggestion that 
they were blisters, bandages were adjusted. 
Twenty-one hours later a decided inflammatory 
reaction was found when the stamps were re- 
moved, and these areas developed, in eight 
more hours, into blisters. After fourteen days 
suppuration still continued. On the other hand, 
by means of suggestion Focachon prevented any 
reaction from a real blister which was applied 
to one arm, while a second one placed on the 
opposite arm produced the usual effect. (Du 
Somnambulisme Provoque, 1886.) Certainly if 
such lesions can be produced with hypnotic 
suggestion then there is no reason why hysteria 
cannot do likewise. 

As the influence of emotional states upon the 
secretions is well known the fact that profuse 
localized or general sweating may occur in 
hysteria is accepted without dispute. 

A remarkable instance has been reported by 
Curschmann. Attacks of sweating appeared 
during what the patient believed was influenza, 
and her daughter became subject to the affec- 



170 Psychopathology of Hysteria 

tion by reason of psychic contagion. Three 
times daily at a fixed hour, and continuing for 
a year, as much as 300 c. c. of perspiration was 
lost at a time. These attacks were unaccom- 
panied by any other physical or psychic dis- 
turbances. Both patients recovered under sug- 
gestive treatment. (Munch. Med. Woch., Aug. 
27, 1907.) 

With hypnotic suggestion one can readily 
induce attacks of profuse hyperhidrosis ; it 
suffices to cause the subject to believe that she 
is becoming disagreeably warm. 

Some neurologists contend that there is no 
such thing as hysteric fever: others are con- 
vinced that fever can occur as a manifestation 
of hysteria. Some observers who limit the 
symptomatology of hysteria to those conditions 
which can be reproduced with hypnotic sug- 
gestion would exclude the possibility of hysteric 
elevations of the temperature. At all events, 
Von Kraff t-Ebing repeatedly was successful not 
only in causing the temperature of lima S. to 
vary as much as 2.5° F., but in causing the 
variations to occur at a fixed hour, and to per- 
sist for days at a time. Reverting to hysteria, 
Osier declares that in at least two of his cases 
a diagnosis other than hysteric fever was im- 
possible. In one of these the temperature rose 
to 102 or 103 every afternoon for four or five 
years. (Principles and Practice of Medicine, 
1902, p. 1119.) 



Visceral and Circulatory Derangements 171 

In 1858 a girl who had been found uncon- 
scious in the street was brought to Bamberger's 
clinic in a delirious state with a tempera- 
ture of 106.7° F. The diagnosis was declared 
to be either typhoid fever or miliary tubercu- 
losis. The following morning all of her symp- 
toms had disappeared; she was well. It was 
found that having been jilted by her lover at a 
dance she became greatly excited, and, while 
running home, had fallen unconscious in the 
street. (Muench. med. Woch., No. 19, 1903.) 

George L. Walton reports a case of hysteria 
in which a temperature of 105 was noticed as 
an isolated symptom that persisted for a week 
and then gradually dropped to the normal dur- 
ing the course of several months. In discussing 
this case Knapp spoke of a case of hysteric 
hemiansesthesia and hemiplegia in which the 
temperature varied from 105 to 95, and Court- 
ney of another hysteric whose temperature had 
been 100 to lOO 1 /^ for several years. (Jour, of 
Nerv. and Ment. Dis., 1907, p. 266.) 

Following an attack of influenza the temper- 
ature of one of my cases of hysteria continued 
at 99 to 100^2 for over a month in the absence 
of any ascertainable cause for the elevation and 
without its being associated with any other 
symptoms. When the regular use of the ther- 
mometer was discontinued the fever immedi- 
ately disappeared. 

After reporting two cases of hysteric hyper- 



172 Psychopathology of Hysteria 

thermia Von Voss concluded that elevation of 
the temperature may occur as a manifestation 
of hysteria in severe cases, and that it often 
accompanies convulsive seizures. (Deutsche 
Zeitschr. fur Nervenheilkunde, Band 30, Heft 
3-4.) 

Naturally, elimination of all possible causes 
for fever other than hysteria is difficult if not 
impossible, but careful observation in these and 
other similar cases which have been reported 
tend to justify the assumption that variations 
in the bodily temperature can be produced by 
hysteria. As already noted the fact that the 
temperature has been altered through the 
agency of hypnotic suggestion by more than 
one observer tends to confirm this belief. 



CHAPTER VI 

Psycho-Motor Disorders 

PARALYSIS. Other than through the 
agency of accidental occurrences there 
is no reason why one hysteric should 
be paralyzed, another afflicted with 
convulsions, and a third contractured. These 
conditions, as well as the other innumer- 
able manifestations which are possible in 
hysteria, really are potential in every case, and 
for that reason justly they may be denominated 
" accidents." One patient has psycholeptic 
attacks and another paralysis simply because 
the first accidentally was exposed to psychic 
contagion as a result of witnessing an epileptic 
attack, and the second is paralyzed because he 
has been subjected to some traumatism which, 
in his opinion, was capable of inducing paraly- 
sis. Casual events and the conceptions of the 
patient determine both the production and the 
character of the various manifestations. 

According to Ziehen the symptoms of hys- 
teria are due to the remarkable vividness with 
which mental representation occurs in this dis- 
ease ; the idea of paralysis being sufficient to 
evoke the symptom. As the idea of paralysis 
may be aroused by numerous kinds of excita- 
tion so the symptom superficially may appear 
to be widely varied in its mode of genesis. 

173 



174 Psychopathology of Hysteria 

When a patient who has slept with the head 
pillowed on the arm develops what should be a 
transient brachial paralysis the condition may 
become fixed and continue as a manifestation of 
hysteria. In the same manner monoplegia may 
be evolved from the transient motor and 
sensory symptoms resulting from undue main- 
tainance of an extremity in a constrained posi- 
tion. In either instance the paralysis should 
be accompanied with anaesthesia because the 
fundamental and temporary organic motor dis- 
turbance having occurred in association with 
numbness both of these symptoms would prob- 
ably become fixed. 

As the effect, too, of the lay conception that 
paralysis necessarily must produce numbness 
the two conditions are usually found together, 
and their boundaries may coincide regardless 
of differences in nerve supply. The pathogenic 
influence of the same conception is noticeable 
in those patients who present impairment of 
strength in members which have become the 
seat of ansesthesia of medical origin. For in- 
stance, the patient is unaware of any disturb- 
ance of sensation or of muscular power until 
she is subjected to examination. Then, without 
being associated with any loss of strength, 
hemianagsthesia, perhaps, is "found." Later 
she returns to complain of muscular weakness 
of the same side of her body. 

The majority of paralyses follow traumatism, 



Psycho-Motor Disorders 175 

and as men are more exposed to injury than 
are women, it is not surprising that this symp- 
tom occurs far more commonly in males. In 
reference to traumatism, one should bear in 
mind the fact that the "accidents" of hysteria 
are dependent upon the psychic effects of an 
injury, and not upon its physical consequences. 
No matter how severe the traumatism may have 
been it is only the idea of injury that eventu- 
ates in hysteric paralysis and other symptoms 
of the disease. As a matter of fact, in cases of 
hysteric paralysis following injury it is not at 
all unusual to find that the injury was but a 
trivial one. Unless deceived by the apparent 
serious import of the symptom the layman is 
inclined to attribute such cases to what is pop- 
ularly termed a vivid imagination, or, if the 
case happens to be one in which a law suit is 
being instituted, the interpretation is more con- 
temptuous. 

Besides those patients with hysteric paralyses 
originating entirely from the psychic effects of 
an injury not infrequently actual, but transi- 
tory, paralysis due to traumatism, or pseudo- 
paralysis of painful injuries, may become elab- 
orated and fixed as hysteric paralysis that con- 
tinues after the organic cause has subsided. 
Thus, paralysis due to traumatic neuritis, or 
pseudo-paralysis consequent upon the pain of a 
sprain, may be the source of hysteric paralysis. 

Two cases which have been reported by 



176 Psychopathology of Hysteria 

Prince illustrate very nicely the genesis of 
paralysis from negligible injuries : During the 
Civil War a round shot, after having knocked 
a tin dipper from the hand of a soldier, passed 
between his elbow and his side. The wind of 
the shot threw him to the ground. Upon re- 
gaining consciousness, twenty-four hours later, 
he presented the same symptoms, he declared, 
as when Prince examined him — decided, but 
not absolute, paralysis and profound anaesthesia 
of the whole left upper extremity. The other 
patient had been struck and rendered uncon- 
scious by some large missile during a battle of 
the Civil War. His blanket roll had so broken 
the force of the blow that, at the time, the only 
sign of injury was ecchymosis below the left 
shoulder ; yet incomplete hemiplegia and hemi- 
anesthesia had developed and persisted. 
(Amer. Jour, of the Med. Sciences, July, 1892.) 
During intense excitement a normal indi- 
vidual may feel that his legs are giving away 
beneath him. Popularly this fact is well 
known; hence the expression "to feel weak in 
the knees." Given a hysteric person who has 
sustained some emotional shock during which, 
among other reactions, this feeling of weakness 
occurred, what is more natural than the devel- 
opment of hysteric paraplegia as a souvenir of 
the incident ? It is the evolution of the physical 
symptoms of hysteria from psychic stresses that 
led Freud to compare them with the monuments 



Psycho-Motor Disorders 111 

which are erected to commemorate important 
historical events. 

The idea of paraplegia may owe its origin to 
the effects of illness. Anyone who has been 
confined to bed several weeks with some severe 
illness is more or less completely unable to 
walk, or to stand alone, when he first rises from 
bed. This actual weakness of the lower ex- 
tremities may continue several days or more, 
and, in a hysteric, it may persist solely as a 
fixed and elaborated symptom of hysteria. In- 
deed, it is from just such conditions that many 
of the manifestations are evolved ; for all have 
some definite exciting cause. Our inability to 
find the precise reason for each symptom that 
every patient presents is only evidence that our 
analyses are incomplete, or defective, and not 
that such symptoms "just happened." 

A beautiful example of the manner in which 
an emotional shock — the idea of injury in this 
case — alone can bring about paralysis is men- 
tioned by Janet: A man had descended upon 
the running board of a railroad coach in the 
attempt, while the train was in motion, to 
change compartments. As the train was about 
to enter a tunnel, while he was still on the run- 
ning board, the idea occurred to him that his 
left side would be crushed. The terror aroused 
by this thought caused him to faint, and he fell 
back into the compartment. Notwithstanding 
that physically he was uninjured, left hemi- 



178 Psychopathology of Hysteria 

plegia developed. (Major Symptoms of Hys- 
teria, p. 141.) 

Whatever the cause, paralysis and other ' ■ ac- 
cidents" of hysteria may not appear at once: 
there may be an intervening period of auto- 
suggestion which may last hours or days, 
and even weeks. During the interval the pa- 
tient may not be consciously brooding over 
the memories of the injury, for these memories 
may have been dissociated from consciousness. 
Later some entirely different event may arouse 
them into pathologic activity with the conse- 
quent production of a paralysis, an amaurosis, 
or some other manifestation. So there may 
occur what may be termed a delayed reaction, 
or a reaction by substitution. Instead, then, of 
hysteric paralysis being evolved from an in- 
jury which might be expected to produce this 
symptom, the patient may develop, for example, 
amaurosis because the mental shock set into 
activity the dissociated memories of some other 
experience whose logical result, amaurosis, re- 
mained latent. 

The diminution of muscular force which is 
met with so commonly during the examination 
of hysteric patients cannot be regarded as in- 
complete paralysis for the reason that it is due 
entirely to the interference of attention with 
the muscular efforts which are being tested. 
Dynamometric investigation of hysterics shows 
that the gripping force apparently is greatly 



Psycho-Motor Disorders 179 

impaired in over 90% of the cases. But when 
these same patients shake hands, or when they 
lift objects which require considerable gripping 
force, one sees at once that the dynamometric 
readings cannot be considered indicative of the 
amount of strength which the patients really 
possess. 

In its distribution hysteric paralysis may af- 
fect a single muscle, or group of muscles, or it 
may assume the form of a monoplegia, a hemi- 
plegia, or a paraplegia. Though the paralysis 
may be complete cases are rarely observed in 
which the patient is totally unable to use the 
affected part. Except its tendency to be asso- 
ciated with anaesthesia, hysteric paralysis fre- 
quently occurs as an isolated manifestation. 
Particularly is this true when the symptom is 
consequent upon traumatism, and when it oc- 
curs in males. 

In those confirmed cases of the hysteric habit, 
or of hysteric malingering in which the disease 
has become but a useful means to an end, or in 
which the patient appears to take great pleas- 
ure in her numerous ailments and who occupies 
herself agreeably in going from one physician 
to another or from this clinic to that, hysteric 
paralysis may be only one symptom of an ex- 
tensive repertoire. In contradistinction to this 
type of patient is the manner in which paralysis 
is regarded by the patient with pure hysteria. 
Such a patient is often quite contented to per- 



180 Psychopathology of Hysteria 

mit her paralysis to continue undisturbed, and 
the interference of a physician may be looked 
upon with indifference, or it may provoke 
active antagonism. She tranquilly ignores what 
ordinarily is considered to be a grave symptom, 
and whether merely inconvenienced, or actually 
incapacitated, she is totally unconcerned about 
her condition. 

Inasmuch as hysteric paralysis is the conse- 
quence of dissociation of the ability consciously 
to evoke motor activity in the affected part there 
should not be any interference with the per- 
formance of automatic or subconscious acts. Ac- 
cordingly, not only should we expect, but actu- 
ally we find, that the paralysis disappears dur- 
ing sleep, hysteric seizures, and, in fact, when- 
ever the usual state of consciousness of the 
patient is in abeyance. The somnambulistic 
attacks of one of Janet's cases demonstrate the 
manner in which paralysis disappears during 
the course of subconscious states. By reason of 
hysteric paraplegia this patient was confined to 
bed. At night, however, he jumped out of bed, 
and, while holding his pillow in the belief that 
it was his child whom he was saving from the 
hands of his mother-in-law, he ran out of the 
room and into the court-yard. Then he climbed 
to the roof of the hospital. Upon being awak- 
ened both of his legs again became paralyzed, 
and it was necessary to carry him back to his 
bed. 



Psycho-Motor Disorders 181 

As the usual state of consciousness of a patient 
is in abeyance during profound hypnosis one 
should be able, through the agency of hypnotic 
suggestion, to secure free use of muscles which 
are the seat of hysteric paralysis. By this means 
not only can one demonstrate the psychic nature 
of hysteric paralysis and therefore differentiate 
the affection from one which is organic, but it is 
possible also to remove the symptom. 

In most cases the diagnosis is a simple matter 
if one studies both the symptom and the patient. 
In the absence of positive differentiating features 
pertaining to the paralysis itself, the discovery 
of other evidences of hysteria cannot be used as 
the basis for a diagnosis because of the fre 
queney with which hysteria and organic disease 
coexist. The character of the symptom and the 
absence of qualities essential to organic paralysis 
alone must be considered. 

Like the distribution of psychic anaesthesias 
the muscles involved in hysteric paralysis may 
not correspond to nerve supply. Except the in- 
considerable wasting of disuse that may occur 
in long standing cases there is not any true 
atrophy of the affected part, nor are there any 
changes in the electrical reactions. In cases of 
hysteric hemiplegia the face is rarely involved. 
On the basis of Briquet's 60 cases of hemiplegia 
examined before 1859 considerable stress has 
been placed upon the statement that the left side 
is affected three times as frequently as the right. 



182 Psychopathology of Hysteria 

Ernest Jones, however, found that the right 
side was the seat of hemiplegia in 54.2% of 277 
cases reported since 1880. (Rev. Neurol, Mar. 15, 
1908.) 

The gait of hysteric hemiplegia differs greatly 
from that of organic disease. When organic the 
patient swings the paralyzed leg forward so that 
the anterior inner surface of the foot describes 
an arc on the floor; the hysteric drags her par- 
alyzed limb behind her just as one would expect 
in consideration of her conception of paralysis 
and her lack of knowledge of how a case of or- 
ganic hemiplegia really should walk. The or- 
ganic hemiplegic wears out the inner aspect of 
the toe of his shoe while the hysteric's shoe is 
more apt to be damaged most at the point. 

When we exert resistance to the muscular ef- 
forts of a patient with incomplete hysteric 
paralysis, and when we study the manner in 
which the non paralyzed hysteric grips the dy- 
namometer, we find notwithstanding that the 
patient appears to be, and is, exerting consid- 
erable strength, and that he fairly trembles in his 
efforts to produce still more forcible muscular 
contraction, yet the results are almost nil. The 
explanation of this apparent diminution of 
strength, and of the seeming disproportion be- 
tween muscular effort and its effects, lies in the 
fact that the contraction of the muscles which 
are being tested is almost neutralized by similar 
activity of their opponents. 



Psycho-Motor Disorders 183 

Of the utmost diagnostic importance is the 
condition of the tendon reflexes. Regardless of 
the presence or absence of paralysis the patellar 
reflexes are slightly, but truly, exaggerated in 
almost all cases of hysteria. Occasionally the re- 
flex may appear to be greatly exaggerated, but 
as this exaggeration usually resembles an inten- 
tional muscular action it cannot be mistaken for 
that caused by organic spastic paralysis. On the 
other hand, the knee-jerks may be greatly in- 
hibited, or even caused to appear to be lost when 
the patient concentrates her attention upon the 
tests and contracts the muscles of the thigh. 
Those who have attempted to demonstrate a nor- 
mal knee-jerk in students have encountered this 
difficulty. Except these known variations of the 
patellar reflex it may be asserted that absolute 
loss, or that true increase to an extent that is 
observed in upper motor neuron type of paraly- 
sis, cannot occur, in a typical manner as the re- 
sult of uncomplicated hysteria. Momentary loss 
of the knee-jerks, however, occurred regularly, 
during the attacks of hysteric petit mal of a 
patient reported by Putnam. (Personal Expe- 
rience with Freud's Psychoanalytic Method, 
Jour, of Nervous and Mental Diseases, 1910, p 
€70.) 

It is stated that 2% of presumably normal in- 
dividuals do not possess knee-jerks. Now, if 
hysteria developed in any of these it might be 
thought that the absence of the reflex was due 
to hysteria. 



184 Psyckopathology of Hysteria 

In uncomplicated hysteria it is not unusual to 
elicit a pseudo-clonus, which, unlike true clonus, 
is not sustained and is semi-voluntary. In ex- 
ceptional instances typical ankle clonus may oc- 
cur, but I have never been able to discover this 
phenomenon among any of my cases until re- 
cently. The patient was a major hysteric who 
had been under observation at intervals for four 
years. Lately the usual type of hysteric hemi- 
plegia developed and there could not be any 
doubt concerning the absence of any organic 
lesion. During one examination a true organic 
type of sustained ankle clonus was found on the 
paralyzed side, but there were no other of the 
physical signs of organic disease. The follow- 
ing day, while demonstrating the patient before 
a section of students, it was impossible to elicit 
even the faintest tendency towards clonus. 

In a case of hysteric convulsive seizures re- 
ported by Heard and Diller the patient had 
bilateral sustained clonus which disappeared 
after two weeks. The patient completely recov- 
ered under anti-hysterical treatment. The clonus 
was believed to be entirely hysteric in origin, and 
in commenting on the case the opinion is ex- 
pressed that ankle clonus is not necessarily in- 
dicative of organic disease ; that it can develop as 
a manifestation of hysteria. (Ankle Clonus in 
a Case of Major Hysteria, Jour, of Nervous and 
Mental Disease, 1910, p. 239.) 

Like the knee-jerks, the Achilles reflex cannot 



Psycho-Motor Disorders 185 

be abolished by hysteria, and, excluding doubt- 
ful reactions to plantar irritation, it is improb- 
able, too, that a typical Babinski reaction can 
be caused by the disease. 

As many cases of multiple sclerosis early in 
their course have been mistaken for hysteria, and 
as clonus, exaggerated knee-jerks, and the 
Babinski sign are common symptoms of this dis- 
ease, it may happen that true organic changes 
in the reflexes may be discovered in cases of 
what appear to be hysteria but which, in reality, 
as later events show, are cases of multiple 
sclerosis. 

There are other organic diseases, too, which 
may be overlooked, and whose alterations in the 
reflexes may be ascribed to what is a superim- 
posed hysteria. 

Probably most authorities believe that the 
reflex changes typical of organic disease cannot 
be produced by hysteria. On the other hand, 
well attested cases of supposedly uncomplicated 
hysteria have been reported by such observers 
as Nonne, Marie, Dejerine, Van Gehuchten, etc., 
in which the Babinski reflex, clonus, and absent 
or exaggerated patellar and Achilles reflexes 
have been found. Even if, as these authorities 
contend, such alterations of the reflexes rarely 
can occur as manifestations solely of hysteria, 
the discovery of these changes in a case of the 
disease argues most strongly for the coexistence 
of organic nervous disease. 



186 Psychopathology of Hysteria 

Of interest are the results of Knapp 's inquiry 
into the condition of the reflexes in 100 cases of 
hysteria presenting a difference in sensibility in 
the lateral halves of the body. He found some 
exaggeration of the tendon reflexes in 86 cases 
and spurious ankle clonus in 7 cases. Of 57 
cases presenting unequal exaggeration of the 
tendon reflexes the increase was found twice as 
often on the anaesthetic side as on the opposite 
one. True ankle clonus, the Babinski sign, and 
absence of the patellar reflexes were not observed 
in any of the cases. Unlike the tendon reflexes 
impairment, or loss, of the skin reflexes of an 
anaesthetic part is not uncommon. In 24 cases 
out of 51 Knapp found the abdominal reflex 
to be involved in this manner. (Jour, of Nerv. 
and Ment. Dis., 1910, p. 93.) 

A valuable means of differentiation between 
organic and hysteric hemiplegia is afforded by 
Hoover's complemental opposition sign. (Jour 
of the A. M. A., 1908, 2, 746.) When a norma] 
individual who is lying upon his back elevates 
one extended lower extremity the downward 
pressure of the opposite heel is increased, and 
when one extended lower extremity is pressed 
down with some force, the downward pressure of 
the contralateral limb is lessened. In eases of 
organic hemiplegia attempts to elevate the 
paralyzed limb result in increased downward 
pressure of the opposite heel, even though the 
paralyzed extremity does not move. Also, eleva- 



Psycho-Motor Disorders 187 

tion of the extended normal limb is accompan- 
ied by an amount of contralateral downward 
pressure that is proportionate to the degree of 
paralysis. If the hemiplegia is hysteric in origin 
the attempt to raise the paralyzed limb does not 
increase the downward pressure of the opposite 
heel, while elevation of the normal limb 
does produce complemental opposition of the 
paralyzed side. In the same manner the com- 
plemental opposition sign may be elicited by 
having the patient press the extremity down 
upon the surface upon which he is lying, in- 
stead of raising, or attempting to raise, the limb. 

In testing patients with moderate organic 
ataxia (Jour, of the A. It A., 1909, 1, 1234.) 
Hoover found that the amount of complemental 
opposition is increased whether the patient's eyes 
are open or closed. But if the ataxia is extreme 
complemental opposition is exaggerated when the 
patient's eyes are open; while it disappears en- 
tirely if his eyes are closed; the patient then 
reacting like the hysteric, or the malingerer. 

As cited by Hoover, Lhermitte found that 
when paralysis of one lower extremity has been 
induced by means of hypnotic suggestion the va- 
riations of complemental opposition are the same 
as those observed in hysteria and malingering. 
In experimenting with hypnotic subjects I have 
verified this when the suggested paralysis was 
complete; otherwise, complemental opposition 
may be the same as that observed with organic 



188 Psychopathology of Hysteria 

paralysis. The same holds true of hysteria. In 
either hysteric or hypnotic hemiplegia the 
absence of complemental opposition depends en- 
tirely upon the fact that the patient is so firmly 
convinced of the reality of her paralysis that she 
really does not attempt to raise the limb. 

When hysteric hemiplegia is spastic then com- 
plemental opposition occurs, but the amount ex- 
hibited when the patient attempts to lift the 
paralyzed limb is not as great as when the nor- 
mal one is elevated. The same result is obtained 
when testing subjects in whom the condition has 
been produced by suggestion. The explanation 
is obvious. Hysteric or hypnotic spastic paraly- 
sis depends upon a more or less constant rigidity, 
and when the patient strives voluntarily to use 
one group of muscles there is a corresponding 
increase in the amount of contraction of the 
opposing group with consequent increase in 
rigidity. Now, if the patient attempts to elevate 
the paralyzed limb the opposing group of 
muscles contract sufficiently to prevent the limb 
from being raised but not enough to maintain 
the same amount of downward pressure that 
had been produced by the weight of the limb 
itself. This result would be expected because 
the patient's conception of her paralysis mere- 
ly prevents elevation of the limb and variations 
in the downward pressure due to its weight do 
not enter into her subconscious calculations. 
Consequently, complemental opposition of the 



Psycho-Motor Disorders 189 

other extremity occurs to a degree sufficient to 
counter-balance this decrease in the weight of 
the affected extremity. 

In the examination of modifications of com- 
plemental opposition Zenner (Jour, of the A. M. 
A., 1908, 2, 1309,) avers that it is easier to de- 
tect contraction of the semitendinosus, the semi- 
membranosus, and the biceps muscles than it is 
to appreciate variations of the downward pres- 
sure of the heel. 

Another sign which is dependent upon com- 
plemental opposition has been described by 
Kaimiste (Rev. Neurol., Feb. 1909.) While the 
patient, with both lower extremities abducted, is 
lying upon a smooth, firm surface the physician 
requests him to draw, but not to lift, the normal 
extremity over towards the paralyzed one, and, 
at the same time, the physician forcibly opposes 
the movement. If the hemiplegia is organic, 
abduction of the paralyzed limb occurs. In like 
manner abduction of the paralyzed member 
takes place when both lower extremities are in 
apposition and the normal one forcibly is pre- 
vented from being separated from its fellow. 

A type of progressive muscular atrophy be- 
ginning in the iliopsoas muscles has been 
described by Thomas Buzzard, who points out 
the difficulty of differentiating the condition 
from some kinds of hysteric paraplegia. (On 
the Simulation of Hysteria by Organic Disease 
of the Nervous System, 1891, p. 5.) In cases 



190 Psychopaihology of Hysteria 

presenting this unusual variety of onset of pro- 
gressive muscular atrophy the patient com- 
plains of weakness in the lower extremities, 
together with difficulty in ascending stairs, in 
walking uphill, or in rising from a chair, yet, 
if the disease is confined to the iliopsoas 
muscles, examination shows that the reflexes 
and electrical reactions which are capable of 
being elicited are normal, and that not any 
atrophy is in evidence. The diagnosis in such 
cases depends upon the character of the motor 
disturbance and upon the absence of signs of 
hysteria. If the disease has spread to the 
muscles of the thigh then the loss of the 
patellar reflexes, changes in the electrical re- 
actions, and the appearance of atrophy, make- 
the recognition of the disease an easy matter. 
A paralysis which is accidentally suggested 
upon a patient owes its continued existence to 
the patient's belief in his inability to activate 
the affected muscles. Consequently, if he can 
be induced to believe that paralysis no longer 
exists, the symptom will disappear at once, or 
if he can be convinced that some form of treat- 
ment is going to "cure" the paralysis, then 
the condition should vanish either suddenly or 
gradually. On the other hand, if the patient 
does not receive any treatment the paralysis 
will continue until some accidental occurrence 
causes him to recover the use of the affected 
muscles either by inducing him to expect recov- 



Psycho-Motor Disorders 191 

ery, or suddenly by arousing the conviction 
that the paralysis no longer exists. 

It is only by reason of the state of expectancy 
which is induced in a devout hysteric that sin- 
cere faith in the miraculous curative virtues of 
a relic is capable of producing immediate cure 
of paralysis, amaurosis, etc. Each shrine has 
its quota of crutches which were discarded by 
cases of hysteric paralysis that were cured. 
For the same reason any worthless patent medi- 
cine, electric belts, tractors, magnets, and kin- 
dred "therapeutic" agents will be effectual, 
providing that the patient has sufficient faith in 
the means. With most of the monosympto- 
matic cases it is a question only of combatting 
one belief with another, and the stronger one 
wins. 

Recent hysteric paralysis usually is very 
amenable to treatment. On the contrary, long 
continued paralysis tends indefinitely to per- 
sist, regardless of treatment. Hemiplegia and 
two instances of brachial monoplegia had con- 
tinued for 29, 28, and 30 years respectively, in 
the three old soldiers with hysteric paralysis 
reported by Prince. 

Systematized Paralysis. Paralysis is sys- 
tematized when it exists only for the conscious 
performance of certain acts; other forms of 
conscious activity with the same groups of 
muscles not being impaired. Through the 
agency of hypnotic suggestion not only can we 



192 Psychopathology of Hysteria 

produce ordinary psychic paralysis, but sys- 
tematized paralysis also can be created; and 
either of such types present all the character- 
istics of those due to hysteria. If we tell a 
hypnotized subject that he is unable to walk 
and then by means of post hypnotic suggestion 
cause the resulting condition to persist after 
the hypnotic state has been removed, different 
types of astasia-abasia can be evolved which 
cannot be differentiated from the varieties met 
with in hysteria. Let us consider, then, that 
hysteric paralysis and systematized paralysis are 
the consequence of dissociation from conscious- 
ness either of all forms, or of particular kinds 
of motor functions in a part or parts, and that 
this dissociation is affected by autosuggestion. 

Astasia-Abasia. In the affection known as 
astasia-abasia the patient is unable normally 
to stand or to walk without, however, any other 
kinds of activity of the lower extremities being 
impaired. Total inability to walk is occasioned 
when the condition is highly developed. More 
frequently some peculiar type of gait is pos- 
sible. Except as the result of abnormal idea- 
tion astasia-abasia would be impossible. It is 
only a psychopathic state which is capable of 
producing inability to walk in a patient whose 
muscles are not paralyzed or ataxic and who, 
perhaps, is able to run and to dance. 

To illustrate a mode of genesis of astasia- 
abasia, and at the same time to demonstrate the 



Psycho-Motor Disorders 193 

importance of autosuggestion in the produc- 
tion of symptoms of hysteria, there is no better 
instance than that afforded by Prince 's B. C. A. 
case of dissociation of personality. (Jour, of 
Abnormal Psych., vol. 3, p. 331.) As person- 
ality C, the patient had witnessed the peculiar 
gait of a patient with astasia-abasia. The co- 
conscious personality B, (what might be termed 
an emancipated subconsciousness) became in- 
terested in the condition, and later, while 
thinking deeply on the subject and wondering 
how it would feel if she were afflicted with the 
same infirmity, personality C became much 
excited and the condition developed. 

Like paraplegia, astasia-abasia may develop 
from the transitory difficulty in standing, or 
walking, that a hysteric may experience after 
having been confined to bed for a number of 
days by some acute illness. 

Mutism. Hysteric mutism is the most in- 
teresting of the manifestations due to system- 
atized paralysis. It may be looked upon as a 
systematized paralysis because the articulatory 
muscles may be affected only for speech. The 
symptom is decidedly more frequent in males 
than in females, and often it occurs as a more 
or less isolated physical manifestation. As 
noted in the section devoted to audition, hys- 
teric mutism may be associated with psychic 
deafness. Having heard of deaf and dumb 
asylums and of the deaf and dumb the two sen- 



194 Psychopathology of Hysteria 

sory deficits are rather intimately associated in 
the minds of laymen. As a consequence of 
this conceptual relationship a hysteric layman 
who becomes deaf may also develop mutism, or 
vice versa. Another mode of genesis is by 
means of fixation and elaboration of an aphonia 
which was symptomatic of some transient local 
inflammation. 

Temporary disturbance, or even total sup- 
pression, of speech is a normal accompaniment 
of intense excitement. An angry man often 
stutters out his rage, or is rendered speechless 
for a brief period. The tendency of hysteria 
to appropriate whatever suggests itself during 
periods of emotional excess, and to elaborate 
normal reactions, may eventuate in the devel- 
opment of mutism, or of other speech defects, 
from just such a transitory difficulty. For ex- 
ample, a patient reported by 0. S. Hubbard, 
(Jour, of the Kansas Med. Soc, 1908, p. 451) 
had become angry and much excited. Mutism 
developed the evening of the same day; sev- 
eral hours after he had expressed the opinion 
that soon he would be unable to talk. By 
means of suggestion, bitter medicine, and mas- 
sage of the neck, speech was caused to return 
the following day. 

Like other phenomena of the disease the 
symptom may be paroxysmal or constant; 
paroxysms being aroused by association of 
ideas. The attacks of mutism occurring in one 



Psycho-Motor Disorders 195 

patient were induced only by quarrels, and it 
was found that some few years ago the initial 
disturbance followed a quarrel with her 
brother. In her early childhood another pa- 
tient had fallen from a tree with the conse- 
quence that a prolonged attack of mutism oc- 
curred. During the succeeding twenty-five or 
thirty years she had been subject to paroxysms 
of mutism that occurred about two or three 
times a year and which continued for a few 
weeks ; the longest having lasted three months. 
Each of the attacks followed some exciting 
incident, and the mutism was absolute — she was 
unable to talk, whisper, or even to whistle. 
Being accustomed to the seizures she neither 
feared nor worried about them. 

An account of an interesting case of mutism 
that occurred during the seventeenth century 
was discovered by Jahnel in an old book. Fol- 
lowing a narrow escape from drowning the 
patient, aet. 10, developed complete mutism. 
For fifty years he was able to speak only 
from noon until one o'clock, and even 
though no clock was at hand he was accu- 
rate to a minute in his determination of these 
hours. Except two or three days before his 
death only twice was he known to speak at 
other hours, and on both of these occasions he 
was ill from fever. (Nerologisches Central- 
blatt, June 1, 1908, p. 512.) 



196 Psychopathology of Hysteria 

The psychic effects of traumatism and the 
occasional resistance of hysterical symptoms to 
treatment is shown in a case reported by J. K. 
Mitchell. (Jour, of Nerv. and Ment. Dis., 1907, 
p. 253.) In a male of twenty- two years abso- 
lute mutism succeeded a stuporous condition 
which had been induced by the psychic stress 
occasioned by contact with a live wire, though 
no other physical effects than a small brush 
burn of the face were discovered. Once dur- 
ing the course of the mutism the patient was 
known unconsciously to have uttered a few 
words, and, on another occasion, he talked in 
his sleep. Local faradism, injection of strych- 
nine, suggestion during a state of light hyp- 
nosis, general anaesthesia, and attempts at vocal 
re-education were unsuccessful in causing the 
return of his speech. Fifteen months after the 
onset of mutism recovery occurred spontan- 
eously during a theatrical crisis. 

On recovering consciousness, after having 
been injured, one of Bailey's patients had mut- 
ism in addition to other major symptoms of 
hysteria. Many months later he was much 
alarmed, after a second accident, to find that 
he was talking to himself — the mutism had dis- 
appeared. The diagnosis, traumatic hysteria, 
was considered incontestable. (Diseases of the 
Nervous System Resulting from Accident and 
Injury, 1906, p. 448.) 

In the normal person a nightmare usually 



Psycho-Motor Disorders 197 

causes a sense of depression during the follow- 
ing day. In our relations with psychopathic 
individuals it is not at all unusual to observe 
that incidents of dreams have been carried 
over into the waking state. One of Prince's 
cases serves nicely to illustrate this mode of 
genesis of symptoms. (Jour, of Abnormal 
Psychology, vol. 5, p. 139.) During a terrify- 
ing dream the patient tried to call to her 
mother, and, as usually is the case during 
dreams, she was unable to speak. After wak- 
ing she could only whisper, and the complete 
aphonia persisted until relieved by suggestion. 

Hysteric mutism may be interpreted as a 
massive dissociation from consciousness of the 
faculty of vocal expression of language. When 
mutism is systematized it may be dependent 
either upon inability to articulate, though inter- 
nal language is unaffected, or upon dissociation 
of the memories of certain kinds of words. The 
defect in the latter instance is more properly 
classified as a systematized amnesia. 

Like most other symptoms of the disease all 
the varieties of mutism readily can be repro- 
duced by means of suggestion. And whether 
the affection be caused by hysteria or by inten- 
tional suggestion, it is the product of a fixed 
idea. The patient sincerely believes that he is 
unable to speak, and, therefore, he does not 
voluntarily try to do so. Or, if at the instiga- 
tion of others he does attempt to speak, his 



198 Psychopathclogy of Hysteria 

efforts are vitiated by his conviction that they 
will fail. In other words, no matter how 
earnest the patient may seem, his attempts to 
speak necessarily must fail by reason of the 
autosuggestion of failure that is implied by 
his lack of conviction in their success. Any 
method, then, which is capable of arousing the 
patient's belief in his ability to speak should 
be successful in the treatment of this condition, 
and it is this fact which enables the believer 
in Christian Science, or in faith cure, or in 
patent medicine, to be cured by these supposed 
therapeutic agents. The fact that they do cure 
justifies the use of the principle upon which 
they are based; namely, suggestion. 

Besides mutism numerous speech defects may 
occur in hysteria. Among these loss of the 
voice with preservation of whispered speech — 
aphonia — probably is the most common. Dif- 
ferent kinds of stammering may occur, and 
even the scanning speech of multiple sclerosis 
may be mimicked. In one rather unusual case 
the patient separated each word and each syl- 
lable by a short quick inspiration so that his 
speech resembled that taught to patients as one 
of the features of a certain method of treat- 
ment of stammering. 

Mutism is rare, if it occurs at all, in psychas- 
thenia; but the majority of inorganic speech dis- 
turbances other than mutism probably are symp- 
tomatic of this psychoneurosis. Ordinary stam- 



Psycho-Motor Disorders 199 

mering and other spasmodic vocal affections of 
like nature almost invariably are due to psychas- 
thenic tics affecting speech, and their mechanism 
differs not all from that of other tics, or "habit 
spasms. ' ' 

Contractures. When a muscle, or a group 
of muscles, develops a state of paroxysmal 
or constant contraction the resulting condition 
is known as a contracture. Almost invariably 
contractures are the effect of the psychic stress 
occasioned by some traumatism; severe, trivial, 
or supposititious. This symptom is not frequent 
for the reason that its causes are also the causes 
of paralysis, and as patients possess greater 
knowledge of paralysis than of contractures the 
former are more apt to occur. 

Like the genesis of paralysis it is not the in- 
jury itself which causes the symptom, but it is 
the idea of the injury. In fact, a contracture 
may appear solely as the result of belief that 
an injury has been received when, in reality, 
none had been inflicted. Florence K, for ex- 
ample, believed that her finger had been kicked. 
Upon questioning her it was found that she was 
not sure that her hand actually had been struck. 
Besides, not any evidence of injury could be dis- 
covered. Immediately after the exposure to in- 
jury she experienced severe pain, and the little 
finger became contractured into the palm. The 
attempts of other physicians forcibly to reduce 
t;he contracture had failed because of the in- 



200 Psychopathology of Hysteria 

tense emotional reaction provoked by such pro- 
cedures. 

On the third day my examination showed that 
even when moderate efforts were made passively 
to extend the finger the exaggerated manifesta- 
tions of pain became excessive, and the more 
forcible the attempt the more pronounced be- 
came the contraction of the muscles which were 
responsible for the condition. The whole hand 
was cold, perspired freely and presented a de- 
cided tremor even before any manipulation was 
attempted. Having hypnotized the patient the 
finger was straightened without difficulty and 
without causing any "pain." When the hyp- 
notic state was dispelled, however, the contrac- 
ture reappeared in spite of previous post hyp- 
notic suggestions which had as their end the 
prevention of this occurrence. Accordingly, she 
was hypnotized again, the finger straightened, 
and a splint applied. When "awakened" she 
expressed surprise at finding her finger ex- 
tended. After about fifteen minutes the splint 
was removed and she had no further trouble 
either from pain or from abnormal muscular 
contraction. 

Contractures may occur in any part of the 
body, and, what indeed is remarkable, even in- 
voluntary muscles may be affected. Except some 
of the contractures produced by involuntary 
muscles all those of hysteria can be duplicated 
by means of suggestion. 



Psycho-Motor Disorders 201 

When originating from traumatism the loca- 
tion of a contracture depends upon the site of 
injury, and the pain which is often found in 
association either is entirely psychic, as in the 
case just mentioned, or it is an elaboration of 
actual pain. Naturally a patient would believe 
that any injury which is severe enough to re- 
sult in a contracture should be provocative of 
considerable pain. When pain, then, is present 
its severity is apt to be out of proportion to 
the amount of surgical injury. 

The recognition of hysteric contractures is 
usually not difficult. When the affection has ex- 
isted for a long time and when the associated 
symptoms are misleading it is quite possible, 
however, to attribute the manifestations to some 
organic disease. In fact, even as great a 
clinician as Osier speaks of having repeatedly 
demonstrated as a typical example of lateral 
sclerosis a case of hysteric contracture of 
paraplegic form. (Practice of Medicine, 1902, 
p. 1114.) 

When the symptom is due to hysteria the 
tendon reflexes are not disturbed as in organic 
nervous diseases, and the electrical reactions 
more nearly resemble the normal. If the flexion 
or extension is not complete examination shows 
that the contraction of the muscles responsible 
for the condition is counterbalanced by con- 
traction of their opponents. Now suppose we 
examine a case of flexion of the forearm. When 



202 Psychopathology of Hysteria 

we attempt forcibly to extend the forearm the 
biceps is felt to contract energetically and the 
counterbalancing contraction of the triceps 
disappears as our efforts at extension render 
this no longer necessary. On the other hand, 
if we try to increase the amount of flexion of 
the forearm we find that the biceps relaxes and 
the triceps becomes tense. 

If a whole extremity is contractured as a re- 
sult of organic disease it is possible to ex- 
tend more or less completely one part at a 
time, but the whole limb cannot be extended at 
the same time. The amount of extension secured 
in this manner is augmented when the flexion of 
neighboring parts is increased. These results 
cannot be secured with hysteric contractures. 

Osseous deformities and joint changes ordi- 
narily do not develop in long standing cases 
of hysteric contracture. With patients in 
whom the condition is not highly organized the 
underlying muscular contraction tends to sub 
side when the patient's attention is distracted, 
and the contracture may disappear during 
sleep, general anaesthesia, the hypnotic state, 
and during somnambulistic or convulsive at- 
tacks. 

The duration of a contracture is variable. 
Like other symptoms it has been known to per- 
sist many years. 

In the treatment of contracture quite com- 
monly advantage is taken of the relaxing effects 



Psycho-Motor Disorders 203 

of etherization in order to reduce the deformity 
and to splint the affected part. Having con- 
vinced the patient that reduction has been 
effected the contracture does not tend to recur, 
but it would be preferable to leave the splints 
in place for several days, or more, according to 
the duration and the severity of the affection. 
This means of treatment is to be recommended 
only as a last resource. Not only is etherization 
disagreeable and not entirely devoid of danger, 
but it may serve as the source of various other 
manifestations of hysteria. "Whether carried to 
the extent of actual hypnosis or not, suggestion 
should be quite as effectual, and without any 
of the disadvantages and dangers of general 
anaesthesia. In order to obtain the greatest 
amount of benefit from suggestion it should be 
reinforced — disguised — by the employment of 
various other agents, such as electricity and 
massage. 

Motor Disorders of the Eye. Among the 
most interesting and the most incomprehensi- 
ble of the special types of contractures and 
paralyses are some of those occurring in the 
eye. It is impossible, however, to describe 
each of the many forms of ocular disturbances 
in a general work, so brief mention is made only 
of a few. 

Hysteric contracture of the orbicularis pro- 
duces unilateral or bilateral drooping of the lids 
which should not be mistaken for organic ptosis. 



204 Psychopathology of Hysteria 

Continual blinking of the lids, blepharoclonus, 
is less frequent in hysteria than in psychasthenia. 
Occasionally one meets with hysteric patients 
who seem unable to displace the eyeballs in any 
direction, but this apparent ophthalmoplegia 
externa usually can be demonstrated to be en- 
tirely subjective. Frequently the condition is 
apparent only during examination of the ocular 
muscles — it is suggested upon the patient. Such 
" paralyses ' ' usually disappear when the pa- 
tient's attention is distracted from the eyes. 

Four years after having sustained a fracture 
of the skull and of the second cervical vertebra 
a male patient developed cerebro-spinal menin- 
gitis. (N. Y. Med. Jour., Dec. 5, 1908.) During 
this illness there appeared indisputable organic 
ophthalmoplegia interna and externa which con- 
tinued for many weeks after his recovery. Sub- 
sequently it was noticed that he was unable to 
move his eyes more than one-fourth of an inch 
in any direction, and bilateral ptosis was con- 
spicuous. That the former organic ophthalmo- 
paresis persisted as a purely hysteric manifesta- 
tion was made apparent by the disappearance of 
the paretic symptoms whenever the patient's 
attention was distracted. 

Conjugate deviation of the eyes and appar- 
ent paralysis of associated ocular muscles are 
readily understood, but it is difficult, indeed, 
to comprehend how hysteria is capable of 
causing paralysis of individual ocular muscles — 






Psycho-Motor Disorders 205 

of producing conditions which one cannot vol- 
untarily reproduce, or which cannot be dupli- 
cated by hypnotic suggestion. Nevertheless, 
quite a few cases have been reported in which 
such paralyses have occurred seemingly as 
manifestations of hysteria. Onuf satisfactorily 
accounted for a case of hysteric spastic conver- 
gence and other ocular symptoms as having 
been due to the elaboration of visual symptoms 
produced by myopic astigmatism. (Jour, of 
Abnormal Psychol., vol. 2, p. 155.) Probably it 
is only our own ignorance which prevents us 
explaining on psychic grounds all the different 
hysteric affections of the ocular muscles. 

As cerebral syphilis often causes isolated 
ocular palsies that may not be associated with 
other obvious evidences of the disease, and as 
the same may occur infrequently with other 
organic nervous diseases, one should exercise 
the greatest care before ascribing these signifi- 
cant affections to hysteria. 

Quite commonly the pupils are a little larger 
than usual, and, in rare cases, pronounced 
mydriasis with loss of the light reflex has been 
noted. Such conditions are thought to be due 
to contraction of the dilator muscle of the iris. 
Redlich (Deutsche Med. Wochenschr., 1908, p. 
313,) reported a case in which widely dilated 
pupils and loss of reaction to light were pres- 
ent only during hysteric seizures that did not 
occasion loss of consciousness, and which were 



206 Psychopathology of Hysteria 

characterized by crying out, and muscular 
activity. The same pupillary phenomena de- 
veloped when the patient was induced volun- 
tarily to reproduce the attacks, provided that 
the muscular contractions were forcible and 
persistent. He believed that the contraction of 
the muscles of the neck so irritated the cervical 
sympathetic as to produce mydriasis, and that 
in this case the condition was but an exaggera- 
tion of the dilatation which normally occurs 
during strong muscular efforts. 

During the attacks of the case of hysteric 
petit mal reported by Putnam, and which was 
mentioned in reference to loss of the patellar 
reflexes, the patient regularly lost the pupillary 
light reflex for several minutes. 

Polyopia and monocular diplopia are so read- 
ily explained by the assumption that the multi- 
plication of images is entirely psychic that the 
involved theory of unequal refraction of the 
lens due to ciliary contractures need not be con- 
sidered except, perhaps, in rare instances. 
Prince's patient with monocular polyopia saw 
such a large number of images that he had dif- 
ficulty in counting them. (Amer. Jour, of the 
Med. Sciences, Feb., 1897.) 

Motor Trepidation. During the examination 
of nervous patients often a rapid tremor of 
small amplitude is noticed when the patient 
is directed to hold out her hands with 
the fingers extended. Such a tremor, one 



Psycho-Motor Disorders 207 

which might be accurately designated an at- 
tention tremor, is dependent upon the familiar 
effects of conscious attention upon the per- 
formance of an act, and it is found sometimes 
even in individuals who do not seem to be ner- 
vous. More important are the slow tremors of 
large amplitude that exist independently of ex- 
amination. These tremors may be localized or 
general, and they may appear only when the 
part is at rest or only during use of the mem- 
ber. 

The differentiation of the intention tremor of 
multiple sclerosis from that which may occur 
as a symptom, of hysteria may be difficult when 
other manifestations are present which are 
common to either disease. Less frequently, 
in addition to rest tremor other symptoms of 
paralysis agitans may be mimicked. Thus a 
patient reported by Gaussel developed by 
psychic contagion all of the manifestations pre- 
sented by a patient with paralysis agitans who 
occupied the next bed. (Gazette des Hopitaux, 
Nov. 7, 1908.) 

The possible causes of hysteric tremor are in 
numerable. Generally the different kinds of 
motor agitation are exaggerated but persistent 
emotional reactions which are elaborated from 
ones which were normal. While committing a 
reprehensible act the arm, for instance, which 
is employed may tremble as normally it might 
in consequence of emotional excitement. By 



208 Psychopathology of Hysteria 

autosuggestion this normal trembling may be- 
come fixed upon the patient. When originated 
in this manner it is a symbol of some repulsive 
act whose memories, because of their unpleas- 
ant nature, the patient has voluntarily sup- 
pressed from consciousness. 

Another mode in which a localized tremor 
may be generated is that in which the patient's 
attention is concentrated upon the activity of 
some one member while a general trembling is 
present as the result of some emotional dis- 
turbance. While shaving a customer a hysteric 
barber became excited, and the consequent 
trembling resulted in the infliction of a severe 
incision. As his livelihood depended upon the 
steadiness of his hand the barber worried about 
his mishap. If the accident were repeated he 
might lose his place. With this foundation of 
expectant attention what might be expected 
actually appeared; whenever he attempted to 
shave anyone, thought about doing so, or even 
fixed his attention upon his hand, decided 
tremor developed in the hand which he used in 
shaving. 

The surgeon often notices severe trembling of 
injured limbs. If the patient happens to be a 
hysteric fixation of this otherwise transitory 
symptom is almost inevitable. Not infrequently 
the irregular movements of chorea are continued 
indefinitely through the agency of associated 
hysteria. 



Psycho-Motor Disorders 209 

The effect of attention upon hysteric tremors 
is variable. Distraction of the patient's atten- 
tion may either increase or decrease the inten- 
sity of the tremor, and concentration of attention 
upon the affected part may also have the same 
varying effects. In psychasthenia, however, a 
tremor always is diminished or caused to disap- 
pear during distraction of the patient's atten- 
tion. 

Khythmical choreas are characterized by 
rhythmical, purposive, involuntary movements 
which do not resemble the aimless jerking of 
chorea; neither are they like the vibrations of a 
tremor. Unlike psychasthenic choreiform tics 
the rhythmical choreas of hysteria do not tend 
to disappear during distraction of the patient's 
attention because the whole mechanism is sub- 
conscious. The agitation may be paroxysmal or 
more or less constant. In the case of the former 
each paroxysm is excited by a stimulus which, by 
association of ideas, provokes into activity the 
dissociated system. The movements may origi- 
nate from dissociated ideas concerning the occu- 
pation of the patient, or they may be represen- 
tations of some disagreeable experience. 

Hysteric tremors and rhythmical choreas may 
be looked upon as rudimentary convulsions. 
Sometimes they are residues of former convul- 
sive seizures. Emma P., for instance, had been 
shot in both arms, and, at the same time, she 
had received an abrasion of the forehead. Imme- 



210 Psychopathology of Hysteria 

diately she became unconscious and a convulsive 
seizure appeared — the first she had ever experi- 
enced. Following this attack she had others 
during which she screamed and struggled. After 
these crises had spontaneously disappeared gen- 
eral trembling and choreiform movements de- 
veloped and continued for seven years. The 
only way in which she could prevent her head 
from participating in this constant motor agita- 
tion was by means of holding it firmly with her 
hands. Furthermore, she had suffered from at- 
tacks of what appeared to be typical migraine 
since she was injured. 

Here, then, is a case in which severe general 
trembling originated from what probably were 
defensive movements of former somnambulistic 
attacks, and these seizures, in turn, represented 
her terror and resistance when she was shot. 
The original pain produced by the abrasion of 
her forehead probably served as the source of 
her ' ' migraine. ' ' The tremor, choreiform move- 
ments, and headaches were readily controlled 
by suggestion during a state of deep hypnosis, 
and, after the third treatment, her symptoms en- 
tirely disappeared. 

The majority of habit spasm or tics are symp- 
tomatic of psychasthenia. The psychasthenic 
tic differs from the rhythmical choreas of 
hysteria in that to a great extent it is volun- 
tary. The patient is obsessed with the idea to 
tique, and temporarily to relieve the mental 



Psycho-Motor Disorders 211 

discomfort due to the impulsion he voluntarily 
indulges in the spasmodic muscular contraction. 
When his attention is distracted his tic is less 
frequent or it disappears, or, to express the 
condition more correctly, he does not have the 
tendency to tique when his attention is dis- 
tracted. 

The imperative ideation which causes the 
psychasthenic tic is disposed to be most insist- 
ent when the spasms are least desired. When 
in the company of friends, and more par- 
ticularly strangers, the patient, always em- 
barrassed and self-conscious, fears that he will 
be afflicted with his tic, and, being ashamed of 
it, he apprehends having remarks made about 
his condition. The consequent state of ex- 
pectant attention naturally results in the pro- 
duction, or the aggravation, of the tic. 

The psychasthenic is able more or less suc- 
cessfully to resist the impulse to tique until he 
believes himself to be unobserved. Then he 
indulges in the relief afforded by a number of 
quickly repeated spasms which appear, to the 
chance observer, as if the impulses had been 
accumulating, or as if the tiquer were at- 
tempting to insure a succeeding interval of 
respite by reason of excessive indulgence. On 
the other hand, the hysteric is not embarrassed 
by her tic, and, in fact, she may not even be 
aware of the muscular contractions which are 
taking place independently of any conscious 
impulsion. 



CHAPTER VII 

Psycholepsy* 

THE failure of the Salpetriere school, 
during Charcot's time, to accede the 
contentions of Berheim, to the effect 
that suggestion plays a most impor- 
tant role in the genesis of symptoms of hysteria, 
resulted in the artificial development, by them, 
of a type of convulsion which was much less 
frequently encountered by other observers and 
which is rarely seen at present, unless produced 
in a similar manner, or unless accidentally and 
spontaneously generated. 

Because of the vast amount of research con- 
cerning hysteria which was carried out by 
Charcot and his followers, and because of the 
persistent manner in which their classic de- 
scriptions of a single variety of hysteric con- 
vulsion have been, and are being, incorporated 
in all text books of nervous diseases, it is quite 
generally thought that this particular kind of 
attack is the only one which may be caused by 
hysteria. Unfortunately, then, our conception 
of hysteric crises is apt to be confused by these 
ubiquitous text-book descriptions of manifesta- 



(*I am indebted to the Editor of the Journal of Ab- 
normal Psychology for permission to incorporate in 
this section material drawn from a previous paper 
entitled "Psychogenetic Convulsions" Jour, of Abn. 
Psych., vol. 5, p. 1.) 

212 



Psycholepsy 213 

tions which were purely the result of most 
elaborate, but unconscious, suggestion and of 
psychic contagion, and which occurred almost 
exclusively in a comparatively small group of 
patients in one hospital. Indeed, the majority 
of text-book considerations of the disease do 
not show that there has been any progress in 
our knowledge of this disease since the time of 
Charcot. This affects more particularly those 
who do not specialize in neurology and who are 
dependent, therefore, upon text-books. Conse- 
quently, these practitioners are led to infer that 
hysterics are capable of presenting only one 
kind of attack — hystero-epilepsy, grande hy- 
sterie, hysteria major — and as the effect of their 
inference other varieties are most apt to be 
looked upon as being epileptic in origin. 

The attack of grande hysterie was divided into 
five stages: (1) The prodromal stage. (2) 
The epileptoid stage. (3) The period of 
elownism, or of movements of wide range. (4) 
The period of emotional attitudes. (5) The 
period of delirium. The following is a sum- 
mary of descriptions of the whole attack as 
elaborated by Charcot, Richer, and others of 
the Salpetriere school: 

1. The prodromal stage is characterized by 
various mental disturbances which may continue 
even for days, or for weeks, before the onset of 
the actual seizure. Objectively, the patient's 
actions deviate markedly from her usual stan- 



214 Psychopathology of Hysteria 

dard; mainly because she becomes unusually 
emotional and irritable. Subjectively, she may 
experience almost any kind of sensory or psychic 
disturbances. The premonitory stage terminates 
with an aura which usually consists of globus 
hystericus, dimness of vision, tinnitus, etc. Fol- 
lowing the aura the patient cries out, falls care- 
fully to the ground, and loses consciousness. 

2. The epileptoid stage. This stage consists 
of a period of tonic rigidity followed by clonic 
convulsions and concluding with muscular re- 
laxation and stupor; the whole lasting but a 
few minutes. 

3. The period of clownism then appears. The 
patient's body is tossed about wildly by reason 
of forcible muscular contractions — of movements 
of wide range — and, most characteristically, the 
highest degree of opisthotonos develops. Towards 
the close of this period she exhibits manifesta- 
tions of great fear, or of rage. Tearing her 
clothes and biting at those who are trying to 
hold her she acts more like a wild animal than 
a human being. 

4. The period of emotional attitudes gradu- 
ally develops from that of clownism after the 
latter has lasted a short time. The attitudes are 
the dramatic representation of various emotions 
aroused by the hallucinations which the patient 
is experiencing, and whose character is depend- 
ent upon the nature of the primary exciting 
cause. In fact, the postures and the type of the 



Psycholepsy 215 

subsequent delirium are indices of the patient's 
ideas at the time. Consequently, they signify 
the original cause of the condition. 

5. The period of delirium is a continuation 
of the stage of emotional attitudes from which 
it differs only in that with the gradual return of 
consciousness the patient gives verbal expression 
to her hallucinations, and the posturing disap- 
pears. 

The entire attack may last from fifteen min- 
utes to an hour, but, in some cases, the pro- 
longation of certain stages, or the occurrence of 
repetitions of some of the stages, or of the whole 
crisis, may cause the condition to persist for 
many hours, and even for several days. Such 
an extended seizure, or succession of seizures, 
then constitutes status hystericus. 

The objection to the elaborate and arbitrary 
descriptions of what is called grande hysterie — 
an attack which was asserted to be character- 
istic of severe hysteria — is that when we dis- 
regard the effects of clinical education and of 
psychic contagion one never encounters a pa- 
tient whose seizures include all, or even most 
of these stages; the reason for this being that 
the so-called hystero-epileptic attack represents 
a composite of a number of the common varie- 
ties of hysteric crises. 

It is significant, indeed, that of the large 
number of cases of hysteria that Janet was 
the first to study only two patients presented 



216 Psychopathology of Hysteria 

crises which conformed to the classic descrip- 
tions of grande hysterie. The same author 
brought together in the same ward three 
hysterics who separately presented three dif- 
ferent kinds of seizures. "I was quite sur- 
prised," he remarks, "to see that after some 
time their symptoms were intermingled and 
that they had all three the same crises, with 
the same movements, the same delirium, the 
same invectives against the same individual. 
Little was wanting for a new type of hysteria 
to be formed in that ward which later might 
have been studied as natural." (Mental State 
of Hystericals, 399 and 406.) 

Grande hysterie is similar to le grande hyp- 
notisme in that the "stages" of each are artificial 
products — clinical artefacts originating in sug- 
gestion and psychic contagion. It is impossible 
to divide hypnotism and the innumerable kinds 
of hysteric crises into stages, for no two patients 
are alike in their hypnotic and hysteric reactions, 
and the nature of either of these conditions de- 
pends largely upon that widely varying factor, 
the individual psychic equation. 

To satisfy that universal scientific desire for 
classification of objects and phenomena that often 
are incapable of being satisfactorily classified, 
we may attempt to divide the many types of 
hysteric crises themselves into what at best can 
be only arbitrary and unstable groups. Then,, 
if the classification is sufficiently comprehen- 



Psycholepsy 217 

sive, we have what is merely a clinically useful 
means of grouping our cases, or of signifying 
in a few words the main features of the attacks 
of some case of hysteria. Therefore, the follow- 
ing incomplete classification may be conven- 
ient : — 

Attacks Characterized Mainly by Motor 
Agitation in Addition to an Altered State 
op Consciousness. 

1. Psycholepsy. 

A. Major epileptiform convulsions. 

B. Focal epileptiform convulsions. 

2. Emotional crises. 



Ambulatory Seizures with an Altered 
State op Consciousness. 

1. Nocturnal somnambulism. 

2. Fugues and ambulatory automatism. 

Attacks whose Main Feature is an Al- 
tered State op Consciousness. 

1. Syncopal attacks. 

2. Petit mal seizures. 

3. Narcolepsy. 

4. Catalepsy. 

5. Trance states. 

6. Ecstacy. 



218 Psychopathclogy of Hysteria 

After making a careful analysis of the his- 
tories of 100 consecutive cases of hysteria it 
was found that 62% had presented one or more 
kinds of hysteric seizures. This percentage 
closely approaches that of Pitres, namely, 63%. 
Eecording only the most severe form of attack 
of each patient it was found that in the hun- 
dred histories examined the incidence was as 
follows : Major epileptiform seizures, 24% ; 
focal epileptiform attacks, 4% ; pseudo petit 
mal, 4% ; ambulatory automatism and fugues — 
"psychic epilepsy" — 3%; narcolepsy, 4%; 
various kinds of simple emotional crises, 8% ; 
syncopal attacks, 15%. Of the major epilepti- 
form variety of hysteric seizure there were 
more than five patients whose crises were iden- 
tical with those of epilepsy, and the proper 
diagnosis of these patients depended entirely 
upon the results of psychoanalysis* and upon 
"cure" by psychotherapy without the use of 
bromides. At least two of the cases of focal 
epileptiform attacks had been diagnosed by 
more than one physician as due to organic brain 
disease. Not a single patient presented seizures 
which even approached the descriptions of 
hystero-epilepsy, but quite a few instances were 
recorded of attacks which resembled more or 
less atypically a single stage, or a combination 
of several stages, of grande hysteric 



*In this work the term psychoanalysis is employed 
comprehensively to designate any researches, regard- 
less of technique, having- as their end the discovery of 
causes of psychopathic conditions. 



Psycholepsy 219 

In describing the seizures of hysteria the se- 
quence which will be observed is neither in 
accordance with the above outline nor is it one 
which is logical; like the classification it is 
merely convenient. 

The emotional crises of hysteria vary in char- 
acter and in severity from simple attacks of 
"hysterics" and of syncope to seizures which 
resemble one or more of the periods of clown- 
ism, emotional attitudes, and delirium of the old 
hystero-epilepsy. The mild types are charac- 
terized by an emotional display of uncontrol- 
able laughing and crying. When the attack 
results from anger the patient may destroy 
objects which happen to come under her obser- 
vation. Ordinarily, such crises are looked upon 
as reprehensible outbursts of temper. When 
more severe the seizure is accompanied by a 
clouded state of consciousness with subsequent 
partial or complete amnesia for the period of 
the attack. 

The different emotional crises may be divided 
into separate stages which vary entirely accord- 
ing to the individual. One patient may suddenly 
become unconscious, exhibit some grand move- 
ments with resistance, and then recover con- 
sciousness without manifesting any other phe- 
nomena. Another one partially loses conscious- 
ness, and, after a period of grand movements 
or passional attitudes, passes into what appears 
to be a state of stupor. After recovering from 



220 Psychopathology of Hysteria 

the attack this patient informs us that while 
lying motionless and apparently unconscious she 
heard everything that was said, but she could 
neither talk nor move. A third ordinary type 
of seizure consists in a somnambulistic state dur- 
ing which the patient hallucinates some former 
episode — usually the one which acted as the ex- 
citing cause of her disease — and repeats more 
or less accurately and intelligibly her original 
reactions. One of the most common kinds of 
simple emotional attacks is characterized by an 
aura, followed by a cry, and loss of conscious- 
ness. The patient falls more or less carefully 
to the floor, undergoes a period of epileptoid 
movements, struggles wildly with those who are 
aggravating matters by trying to prevent her 
from hurting herself, and then recovers con- 
sciousness, usually without presenting any sub- 
sequent stupor. 

The recognition of the many possible kinds 
of elementary emotional crises is without diffi- 
culty. With ordinary care in obtaining a his- 
tory and in making the physical examination it 
should be impossible to make any mistake in 
the diagnosis. The causes, psychic mechanism, 
and treatment of these attacks is the same as 
that of the more grave types of epileptiform con- 
vulsions, and, consequently, these features will 
receive collective attention at the close of this 
chapter. 

In common with other diseases whose nature 



Psycholepsy 221 

has been but illy understood and which have 
served as resources of diagnostic convenience, if 
not ignorance, epilepsy is being diagnosed less 
frequently as our knowledge of this disease pro- 
gresses, but more particularly so as the result of 
our recognition of the fact that epileptiform 
manifestations may occur in diseases other than 
epilepsy, and especially is this true of the func- 
tional neuroses. On the other hand, hysteria and 
psychasthenia are the two diseases the diagnosis 
of which has increased most in frequency at the 
expense of that of epilepsy. Uncomplicated 
neurasthenia, however, probably never causes 
convulsions. 

It is conceded now that the psychoneuroses 
can mimic very closely the different kinds of 
epileptiform attacks. Indeed, not a few cases of 
convulsions of psychopathic origin have been re- 
garded as typical examples of major epilepsy, 
and mistakes are even more frequent in the 
diagnosis of petit mal and "psychic epilepsy." 

Some of those who have made psychoanalytic 
researches of epilepsy and psycholepsy believe 
that a not inconsiderable number of cases of sup- 
posed major epilepsy, many cases of petit mal, 
and all cases which were formerly considered to be 
psychic epilepsy, in reality are not epilepsy, but 
are manifestations of those psychoneuroses which 
clinically are known as hysteria and psychas- 
thenia. George M. Parker, for instance, is radical 
enough to state that "what is often regarded 



222 Psychopathology of Hysteria 

as epilepsy does not really belong there, — that 
many a ' typical ' epilepsy may on a closer study 
turn out to be a functional psychosis. This 
is especially true of the so-called 'psychic 
epilepsies,' which, as the psychopathological 
researches of our laboratory on many other 
different cases incontestably demonstrate, are 
all pure functional psychoses, subconscious dis- 
sociated states, having the tendency to recur, 
periodically or not, with all the energy charac- 
teristic of a fully dissociated system, reproduc- 
ing the original psychomotor conditions dur- 
ing -the accident, and often closely mimicking 
the psychomotor manifestations of epilepsy/ T 
(Psychopathological Researches in Mental Dis- 
sociation, by Boris Sidis, 1908.) 

In speaking of the term psychic epilepsy, Sidis 
writes : ' ' This term, though ambiguous, may be 
accepted, if understood not in the sense of epil- 
eptic origin or, as it is put, 'psychic equivalent y 
of epilepsy, but as epileptoid disturbances of a 
purely mental character due to dissociative 
states of functional neuropsychosis; in the same 
way as, for instance, psychic anaesthesias of 
functional diseases are not equivalents of organic 
neuron degenerations." "The phenomena of 
'psychic' epilepsy are of the nature of post- 
hypnotic automatisms." (Ibid.) 

Since it has been recognized, in the last few 
years, that, in addition to hysteria, psychas- 
thenia also may occasion epileptiform seizures 



Psycholepsy 223 

the differential diagnosis has become even 
more difficult. It cannot be emphasized too 
strongly that the diagnosis epilepsy is justi- 
fiable only when all other diseases which are 
capable of inducing epileptiform attacks, par- 
ticularly hysteria and psychasthenia, either 
positively can be excluded or recognized as 
associated conditions. For it is quite common 
to encounter patients in whom hysteria or 
psychasthenia have been superimposed upon an 
epileptic foundation just as multiple sclerosis 
usually is complicated with hysteria. 

Because an attack per se may possess all the 
features of one due to epilepsy is no reason 
why the patient should be considered as epi- 
leptic. It is granted now that hysterics and 
psychasthenics not only may have auras which 
may be similar to those of epilepsy, but that 
during crises they not infrequently injure 
themselves in falling, have involuntary evacua- 
tions of the bladder and rectum, and bite their 
tongues. The presence or absence, therefore, 
of these accidents no longer can be regarded 
as differential characteristics. ''It is becoming 
recognized," observes Ernest Jones, "that in a 
grand mal attack there may be absolutely 
nothing in the nature of the attack itself to in- 
dicate its source." (Mechanism of a Severe 
Briquet Attack, Jour, of Abnormal Psych., 
vol. 2, p. 219.) 



224 Psychopatkology of Hysteria 

As the psychoneuroses are only closely 
inter-related clinical syndromes which very 
frequently are indistinguishable from one an- 
other it is always difficult, and often impos- 
sible, to differentiate the attacks which may 
occur as symptoms of these conditions. For 
this reason it is often convenient to include the 
psycho genetic crises either of hysteria or of 
psychasthenia under the designation psychol- 
epsy. 

Formerly the French writers applied the 
term hystero-epilepsy to hysteria when this dis- 
ease occasioned what might be called the 
Salpetriere type of convulsion — grande hysteric 
Unfortunately, the significance of this name has 
been degraded by the indiscriminate manner 
in which it is used at present. Beside its 
original connotation it is used by various 
writers to signify the coexistence of hysteria 
and epilepsy, and some have attempted even to 
distinguish a new disease, to which they apply 
this name, which is neither hysteria nor 
epilepsy. As the term is no longer distinctive 
it should be discarded from modern neurologic 
nomenclature. The designations hysteric con- 
vulsions and psychasthenic convulsions are 
ones which cannot be confounded with epilepsy, 
or otherwise misinterpreted, while the term 
Briquet attack is useful to signify the many 
atypical and less completely developed forms 
of hysteric and psychasthenic emotional crises. 



Psycholepsy 225 

It is safe to say that there is no type of 
seizure which is characteristic either of hysteria 
or of psychasthenia, and that because of the 
psychic mode of genesis of manifestations of 
these diseases any kind of attack is possible. 
However, in these psychoneuroses it is prob- 
able that, with the exception of simple emo- 
tional crises, major epileptiform convulsions 
occur more frequently than any other variety 
of seizure. There are two good reasons for 
the preponderance of this type of convulsive 
syndrome : quite commonly psychic contagion 
leads to the development of heterogenous 
psycholepsy, and, secondly, the malady origin- 
ates less frequently autogenically as the direct 
elaboration of normal psychic reactions to in- 
tense emotion. 

It is not at all unusual for normal persons to 
have witnessed, or to have read descriptions of, 
an epileptic crisis, and it is to be deplored that 
cases of psychoneurosis have far greater oppor- 
tunity of acquiring information concerning the 
features of such attacks owing to the fact that 
in hospital practice these unfortunates are usually 
treated in the same wards with epileptics. 

Psycholepsy may develop while the patient is 
exposed to psychic contagion, or the knowledge 
which she has acquired of convulsions may re- 
main dormant until some exciting cause precipi- 
tates the kind of attack with which she is 
familiar, and which she may have feared and 
expected. 



226 Psychopathology of Hysteria 

If we subject all of our cases of psycholepsy 
to a searching inquiry we will find that from 
50 to 75% of the patients have been more or 
less closely associated with epileptics. Also, 
that frequently they have observed epileptic 
convulsions and that their seizures are identical 
with those which they have witnessed. In 
many of these cases we can trace the patient's 
attacks so directly to ones which were observed 
during exciting circumstances in friends or 
relatives that their genesis by psychic con- 
tagion is indubitable. Mention has already 
been made of the son who developed hysteric 
Jacksonian seizures whose features were pre- 
cisely like those of his hysteric mother. In 
another interesting case, one of major epilepti- 
form convulsions due to hysteria, the seizures 
developed after the patient had seen her infant 
brother undergo a large number of convulsions 
during the course of a fatal attack of pertussis. 
Though many similar instances might be cited 
from personal experience one abbreviated 
record is sufficient to illustrate the influence 
of psychic contagion, reinforced, in this case, 
by direct hetero-suggestion. 

Elizabeth M., a mill-girl, aet. 22, had never 
experienced any seizures until July 29, 1907, 
when suddenly, and without afterwards being 
consciously aware of any apparent cause, she 
screamed, ran a few steps, and then fell un- 
conscious. General tonic and clonic spasms 



Psycholepsy 227 

appeared, of which the movements of her jaw 
caused a laceration of the tongue. After a 
postconvulsive stuporous state which lasted 
three hours she regained consciousness, but felt 
exhausted. Upon the advice of her physician 
she remained in bed three days. During two 
nocturnal major convulsions evacuations of the 
bladder occurred. Besides this type of attack 
she had numerous emotional ones which were 
preceded by a peculiar sensation originating in 
the epigastric region and which caused her to 
feel faint. The subjective sensations of the 
attack itself consisted of palpitation, dyspnoea, 
and exhaustion. 

The patient was unaware of the causes of any 
of her manifestations. She knew, however, 
without appreciating its genetic significance, 
that each diurnal attack was preceded by fear 
and expectant attention. Often she would say 
to her mother: "I know that I am going to 
have an attack to-night." Frequently she had 
nocturnal seizures which were succeeded by 
localized amnesia, and which were characterized 
by calling for her parents, irrational talk, and 
apparent fear. 

The statements of the mother, and the results 
of interrogation of the patient before and dur- 
ing hypnosis, indicate that the mechanism of 
genesis of her symptoms was as follows : Until 
she was 15 years of age she had never exhibited 
any manifestations of nervousness; always 



228 Psychopathology of Hysteria 

having been socially inclined and full of fun. 
Her menses did not appear until her twentieth 
year, and following their establishment she 
menstruated only every three months. Because 
her menstrual function was not like that of 
other girls she worried excessively about her 
health. Indeed, she thought that she had an 
abdominal tumor and that surely she would 
die soon. The girls with whom she associated 
encouraged her belief in the serious import at 
first of her failure to menstruate, and later, of 
the abnormal periodicity of this function. 

Now, six months before her first seizure, and 
in her presence, a friend was seized with a 
convulsion. The shock of the incident was in- 
creased and rendered more personal by the 
fact that this friend subsequently told her that 
she was subject to convulsions because of 
menstrual irregularities, and, furthermore, that 
these abnormalities were the same as Eliza- 
beth's, therefore Elizabeth surely would de- 
velop convulsions. Following this accident and 
the suggestive explanation of its cause Eliza- 
beth worried much about the possibility of the 
same condition appearing in herself. Fre- 
quently she asserted that she would become an 
epileptic, and her mother stated that she talked 
constantly about this disease. Finally the in- 
evitable took place ; she began to have con- 
vulsions which at first were exactly like the 
one she had witnessed. 



Psycholepsy 229 

In September, 1908, she became engaged to 
a man who, four months after having impreg- 
nated her, jilted her following a quarrel. Hav- 
ing taken the matter to court and thus secured 
unenviable newspaper notoriety she was ostra- 
cised by her friends. Naturally, these unfortu- 
nate occurrences greatly aggravated her nervous 
condition, and she became obsessed with the 
idea of killing her violator, regardless of the 
consequences. 

The type of attack which simulated petit mal 
developed only after the quarrel. Each of these 
crises was caused either by thinking about her 
troubles, by worrying over the fact that she was 
pregnant, or, subsequently, by reproaching her- 
self for having provoked an abortion by means of 
drugs. The nocturnal attacks were induced by 
thinking of her lover before retiring, or by erotic 
dreams of which he was the subject. A number 
of psychasthenic obsessions with which she was 
afflicted were traced in the same manner to 
the nervous shocks which she had sustained. 

These results of analysis, though apparently 
so simple and so easily ascertained, could have 
been obtained only by means of some psycho- 
analytic method — hypnotism in this case — for 
the reason not only that she was not con- 
sciously aware of the causal relations between 
her various manifestations and the psychic 
stresses, but that some of these had been en- 
tirely forgotten, or suppressed. Without such 



230 Psychopathology of Hysteria 

painstaking research she would have been con- 
sidered an epileptic and treated unavailingly 
as such. 

The diagnosis, psychasthenic convulsions, was 
suggested by the presence of other indubi- 
table evidences of psychasthenia. It was jus- 
tified by the discovery of an adequate and 
direct emotional cause, by the successful re- 
production, through the agency of hypnosis, of 
memories' of events which occurred during at- 
tacks; and by reproduction of memories of a 
subconscious cause for individual seizures. 

During a period of two months the patient 
was treated nine times with hypnotic sugges- 
tion. After the second treatment her obsessions 
disappeared and major convulsions no longer 
recurred. Attacks of pavor nocturnus con- 
tinued to occur much less frequently as the con- 
sequence of dreaming about her former lover, 
and each dream was found to have been pre- 
ceded during the day by conversations about 
this man. Unfortunately, the patient discon- 
tinued treatment before further improvement 
could be obtained. As she had responded so 
well to psychotherapy probably all of her 
neurotic manifestations could have been caused 
to disappear had she continued the treatment a 
little longer. A most detrimental factor in the 
case was the fact of her constantly being re- 
minded of her troubles; her father and many 
of her friends refusing to speak to her on ac- 



Psycholepsy 231 

count of her fall from virtue, and because the 
law suit had not been terminated. 

The influence of contagion in the genesis of 
psychogenetic convulsions is shown even more 
forcibly in epidemic hysteria than in indi- 
vidual cases of the disease. Take, for instance, 
the epidemic of hysteria which reigned among 
the American Indians during the height of the 
ghost dance epoch. At a dance held on White- 
Clay Creek 100 out of 3,000—4,000 Indians 
succumbed to syncopal, convulsive, ecstatic, or 
other seizures. (Fourteenth Annual Report of 
the Bureau of Ethnology to the Sec. of the 
Smithsonian Institution, part 2, p. 917.) Or. 
among civilized whites, about 3,000 persons, or 
one in every six of those exposed, fell to the 
ground with similar crises during one of the 
early Kentucky revivals. (Citation by Daven- 
port, Primitive Traits in Religious Revivals, 
1906, p. 77.) 

Now let us investigate the sources of auto- 
genous psycholepsy. It is well known that any 
emotion tends to produce physical expression 
and that if the emotional perturbation be 
sufficiently intense diffuse muscular activity is 
inevitable. As the normal reaction to any 
severe mental stress, general tremors, convul- 
sive movements, dilated pupils, and flushing, or 
pallor, develop with their associated emotional 
states of fear, anger, etc., according to the 
nature of the exciting cause and according to 



232 Psychopathology of Hysteria 

the individual. If the emotional disturbance 
be sufficiently pronounced then syncope may be 
a terminal phenomenon. 

When occurring in psychopaths these normal 
reactions may become elaborated subcon- 
sciously, by reason of the diminution of 
cerebral inhibition which is characteristic of 
these patients, and they may then occur, in this 
elaborated manner, without being consequent 
upon what normally would be an adequate ex- 
ternal exciting cause ; recurrence being effected 
by pathologic association of ideas. These 
anomalous, or perverted, and elaborated reac- 
tions then constitute psycholeptic attacks. Ac- 
cording to this manner of genesis convulsions, 
if present, are merely the result of elaboration 
of the motor agitation which is a constituent 
of a normal emotional reaction, and the accom- 
panying loss of consciousness is a temporarily 
massive dissociation which is evolved from the 
syncope. 

It does not require any stretch of the imagin- 
ation to conceive how one who is afflicted with 
a disease whose main objective characteristic 
is increased emotivity can develop psycholepsy 
from what normally would be a minor psychic 
stress. If we study the normal reactions to 
excessive emotional states we find, in fact, that 
they very closely resemble epileptic convul- 
sions. In describing the physical expression of 
fear Darwin (The Expression of the Emotions 



Psycholepsy 233 

in Man and Animals, 173, p. 291,) wrote: "As 
fear increases into an agony of terror, we be- 
hold, as under all violent emotions, diversified 
results. The heart beats wildly, or may fail to 
act and faintness ensue; there is a death-like 
pallor; the breathing is laboured; the wings of 
the nostrils are widely dilated; . . . ." 
"The pupils are said to be enormously dilated. 
All the muscles of the body may become rigid, 
or may be thrown into convulsive movements. 
The hands are alternately clenched and opened, 
often with a twitching movement. The arms 
may be protruded, as if to avert some dreadful 
danger, or may be thrown wildly over the 
head." Concerning the reactions to pain the 
same author stated (Ibid. p. 70.) : "With man 
the eyes stare wildly as in horrified astonish- 
ment, or the brows are heavily contracted. 
Perspiration bathes the body, and drops trickle 
down the face. The circulation and respiration 
are much affected. Hence the nostrils are 
generally dilated and often quiver; or the 
breath may be held until the blood stagnates in 
the purple face. If the agony be severe and 
prolonged, the signs all change ; utter prostra- 
tion follows, with fainting or convulsions." 

These descriptions might be applied with 
just as much accuracy to many of the attacks 
of hysteria, for are not these crises only the 
exaggeration of normal reactions? The hys- 
teric emotional reaction is abnormal only in 



234 Psychopathology of Hysteria 

that it occurs in the absence of what normally 
would be considered a commensurate external 
stimulus. Like many other symptoms of the 
disease the exaggeration of reactions represents 
reversion to juvenile types of reaction. On ac- 
count of the psychic instability of children 
moderate pain and emotional disturbances, in- 
stead of being expressed by local convulsive 
movements of the face, and by other lesser 
modes of externalization, arouse a more pro- 
found reaction, so that syncope and convulsions 
may be provoked. 

Granting that psychic contagion was re- 
sponsible for the majority of convulsive attacks 
which occurred so universally during ghost 
dances, Kentucky revivals, early Methodism, 
and in many other religions, victims were re- 
quired to initiate the contagion. Certainly all 
of these could not have been individuals who 
had been previously subject to the malady. 
The convulsions of many of these originators 
of contagion undoubtedly represented simply 
the tendency of extreme mental excitement to 
be propagated as muscular agitation whose in- 
tensity arose to the development of convulsions. 

Besides the evolution of hysteric convulsions 
from normal emotional reactions, there are in- 
numerable ways by which the malady can be 
suggested upon the patient. About 5 or 10% 
of the cases are consequent upon operations. 
The following case is instructive in that it 



Psycholepsy 235 

illustrates how the seizures may be elaborated 
from a surgical experience ; the features of the 
attacks being derived from the reactions to 
etherization and from associated incidents: 

About two weeks after having been operated 
for adenoids a boy of fifteen commenced to 
have daily crises. These occurred at the same 
hour each day, and each was preceded by an 
aura of pain in the left side of his abdomen, 
followed by difficulty in breathing, a sensation 
of constriction in the chest, and by numbness 
and tingling of the whole body. Following 
these sensations he seemed to become uncon- 
scious and general convulsive movements ap- 
peared. The whole seizure lasted about five 
minutes, and after its subsidence he felt weak 
and nauseated. By exerting pressure upon the 
left side of his abdomen the attack could be 
reproduced. 

Now this peculiar type of crisis is easily ex- 
plained from data obtained from the boy's 
father, and from the results of hypnotic psycho- 
analysis. Being greatly alarmed at the pros- 
pects of the operation, which had been per- 
formed one year previously, the patient had re- 
sisted etherization so much that an orderly had 
used decided force in holding him down. Dur- 
ing these struggles the efforts of the orderly 
resulted in the production of pain in the left 
side of the patient's abdomen. About this time 
the effects of the anaesthetic developed; he 



236 PsycJiopatlwlogy of Hysteria 

began to experience numbness and tingling of 
the body. Local irritation from forcing the 
anaesthetic in order more quickly to stop his 
struggles caused a feeling of suffocation. After 
recovering consciousness naturally he felt weak 
and nauseated. Thus all of his symptoms may 
be explained; even the time of onset of his 
attacks corresponded to the time of the opera- 
tion. Though the condition had lasted a year 
one treatment with hypnotic suggestion effected 
a satisfactory cure. 

More interesting is the case of Marie; a case 
reported by Janet, who asserts that it is one 
of the first observations concerning subcon- 
scious fixed ideas in a hysteric: Immediately 
before each menstrual period Marie became 
sombre and violent. Twenty hours after the 
onset of menstruation the flow suddenly ceased, 
and a severe chill shook her whole body. Then, 
following a sharp pain that arose from her 
abdomen to her throat, violent convulsions set 
in, and these, in turn, were succeeded by 
maniacal delirium. (She had been brought to 
the hospital because she was thought to be in- 
curably insane.) For as long as two days the 
stages of delirium and convulsions alternated 
with brief periods of respite, and then, after 
vomiting blood several times, her usual state 
of consciousness returned and she was amnesic 
for the whole of the attack. Being questioned 
as to the manner in which her first menstrual 



Psycholepsy 237 

period had appeared, and had been interrupted, 
she was unable to answer clearly; she seemed 
to have completely forgotten. 

Having remained in the hospital eight 
months without any improvement it was de- 
cided to hypnotize her, and then to endeavor 
to ascertain her early menstrual history. After 
inducing the somnambulistic state of hypnosis 
Janet was enabled to discover the causes of the 
convulsive seizures and of other symptoms 
which do not concern us. When Marie had at- 
tained the age of thirteen her menses first ap- 
peared. Not understanding this phenomenon, 
and laboring under a misapprehension regard- 
ing its cause, she was ashamed, and sought to 
suppress the flow. To this end she went out 
and plunged into a large tub of cold water. 
Twenty hours after the appearance of the flow 
her device was successful; the flow suddenly 
ceased, a severe chill set in, she was delirious 
for several days and ill for a considerable time. 
Subsequently, the menses did not reappear 
during five years and, finally, when they did 
return, they were accompanied by the crises 
which have been described. The onset of each 
menstrual period induced reproduction of the 
pathologic results of the initial suppression 
without, however, reviving the memory of the 
original experience itself. Janet incidentally 
remarks that by modifying the subconscious 
idea he readily caused the attacks and the 



238 Psychopathology of Hysteria 

delirium to disappear. (Mental State of Hys- 
terical^ p. 282.) 

It is, indeed, deplorable that a prolific cause 
of hysteria and its manifestations is the 
culpable ignorance of young girls concerning, 
at least, the menstrual function. Many young 
girls who have not been prepared for the onset 
of menstruation become so alarmed by the first 
indication of a flow that they develop a psy- 
choneurosis with the consequence that each 
subsequent menstrual period acts as the ex- 
citant for some kind of attack. Like Janet's 
case the manifestations are psycholeptic in not 
a few of these victims of a faulty system of 
education. Until a thorough examination had 
been made and the complete history obtained 
one of the most puzzling diagnostic problems 
was presented by just such a case. A young 
married woman had been perfectly well, from 
the neurologic point of view, until her 
thirteenth year when, not having received any 
instruction relative to the function of menstrua- 
tion, the initial onset of the flow so frightened 
her that she became much excited, and then 
maniacal. Subsequently, each menstrual period 
provoked a hysteric crisis, and, as the years 
passed by, these seizures gradually became 
elaborated until they resembled epilepsy so 
closely that this diagnosis had been made by 
more than one physician. 

Just one more example of the manner in 



Psycholepsy 239 

which psycholepsy may be originated. Sallie 
S. had been subject to hysteric crises for eight 
years. At first her seizures were character- 
ized only by uncontrollable crying and laugh- 
ing, but gradually they became more highly 
developed so that finally they were typical of 
major epilepsy. It was found that she had 
never had any attacks, nor symptoms of 
hysteria, until one month after the death of her 
first child. Upon resorting to hypnosis every- 
thing became clear. Each attack was caused 
by chance occurrences, or remarks, which 
caused her to think of her dead child, and just 
preceding the onset of the seizure she experi- 
enced hallucinations concerning the illness and 
the death of this child. During her usual state 
of consciousness, however, she positively as- 
serted that she knew of no cause for her con- 
dition, and that she did not believe that the 
death of her child had anything to do either 
with the illness or with the causation of indi- 
vidual crises. Besides other significant fea- 
tures, the recovery of memories of events 
which took place during her seizures, and the 
fact that she has not had a single convulsion 
since the first hypnotic treatment, are sufficient 
to confirm the diagnosis — hysteric psycholepsy. 
Every emotion tends to some kind of ex- 
pression. When an individual suppresses the 
reaction he performs what in ordinary parlance 
is designated a bottling up of emotion — instead 



240 Psyckopathology of Hysteria 

of dissipating the emotional feeling he pre- 
serves it, with the consequence that it is pro- 
longed only to crop out at intervals. It is a 
fact of common observation that the man who 
gives free vent to his wrath soon forgets its 
cause, while he who suppresses his exhibition 
of anger does not soon forget the provocation ; 
his anger smoulders within him, and both him- 
self and its object long continue to feel its 
effects. For the same reason the most intense 
grief is that which is experienced without any 
outward demonstration. To revert to the 
popular recognition of the effects of emotions 
which have not been adequately expressed we 
have the not uncommon remark — one whose 
truth is affirmed by sound psychologic prin- 
ciples — that is made about an afflicted person: 
"If she could only cry she would recover/ ' 

"We know that dissociation of memory com- 
plexes is only too readily effected in hysteria. 
When a hysteric fails sufficiently to react to an 
intense emotion, or when she voluntarily 
strives to forget the painful occurrence, then 
the complex concerning the episode becomes 
completely submerged into subconsciousness. 
The result of this process is the appearance 
of some kind of psychopathic manifestation 
whenever the dissociated complex is aroused 
into activity by chance association of ideas. A 
hysteric manifestation once having occurred, 
the proper association of ideas should always 



Psycholepsy 241 

tend to reproduce the symptom, just as the 
proper stimulus causes us to remember any 
event in our lives; the odor of a rose tends to 
arouse the different mental images pertaining 
to the conception "rose/' or the sight of the 
ocean may arouse unpleasant sensations in the 
epigastric region of one who has experienced 
seasickness. 

Among other interesting clinical studies of 
the genesis and subconscious mechanism of dif- 
ferent psychoneurotic manifestations Sidis re- 
lates the history of a case which perfectly il- 
lustrates the manner in which association of 
ideas may induce recurrence of psycholeptic 
crises. Part of his account is as follows : ' ' The 
patient complains of 'shaking spells.' The 
attack sets in with tremor of all the extremities 
and then spreads to the whole body. The 
tremor becomes general and the patient is 
seized by a convulsion of shivering and 
tremblings and chattering of teeth. Sometimes 
he falls down, shivering, trembling and shaking 
all over. The seizure seems to be epileptiform, 
only it lasts sometimes for more than three 
hours. The attack may come on any time dur- 
ing the day, but is more frequent at night. 
During the attack the patient does not lose 
consciousness, he knows everything that is 
taking place around him, can feel everything 
pretty well; he only chatters violently with 
his teeth, trembles and shivers all over and is 



242 PsycJiopathology of Hysteria 

helpless to do anything. There is also a feeling 
of chilliness, as if he is possessed by an attack 
of 'ague.' The seizure does not start with any 
numbness of the extremities, nor is there any 
anaesthesia or pargesthesia during the whole 
course of the attack. With the exception of 
the shivers and chills the patient claims he 
feels 'all right.' 

' ' Patient was put into a deep hypnoidal con- 
dition very close to the hypnotic state. There 
was some catalepsy of a very transient char- 
acter, but no suggestibility of the hypnotic 
type. Now in this hypnoidal state it came to 
light that the patient 'many years ago' was 
forced to sleep in a dark, damp cellar where 
it was bitter cold. The few nights passed in 
that cold cellar he had to leave his bed, and 
shaking and trembling and shivering and chat- 
tering with cold he had to go to urinate, fear- 
ing to wet his bed, in expectation of a severe 
punishment. The patient, while in that inter- 
mediary, subwaking, hypnoidal state, was told 
to think of that dark, damp, cold cellar. Sud- 
denly the attack set on, — the patient began to 
shake and shiver and tremble all over, chatter- 
ing with his teeth, as if suffering from great 
cold. The attack was thus reproduced in the 
hypnoidal state. ' This is the way I have them, ' 
he said. During this attack no numbness, 
no sensory disturbances, were present. The 
patient was quieted, and after a little while the 



Psycholepsy 243 

attack of shivering and cold disappeared. Now 
the room in which the patient was put into the 
hypnoidal state was very dark, and acci- 
dentally the remark was dropped that the 
room was too dark to see anything; immedi- 
ately the attack reappeared in all its violence. 
It was found later that it was sufficient to men- 
tion the words 'dark, damp, and cold' to bring 
on an attack even in the fully waking state. 
We could thus reproduce the attacks at will, — 
those magic words had the power to release 
the pent-up subconscious forces and throw the 
patient into convulsions of shakings and shiv- 
erings, with feeling of cold and chattering of 
the teeth." (Studies in Psychopathology, Bos- 
ton Med. and Surg. Jour., Mar. 14, 1907, to Apr. 
11, 1907.) 

Often trauma is one of the factors of the 
emotional stress which terminated in, or was 
followed by, the development of psycholeptic 
seizures. The memory of the resultant pain be- 
comes, therefore, a constituent of the complex 
of the original experience. In fact, the part 
that was the seat of pain may continue in- 
definitely to be painful. In this event the pain 
is symbolic of the accident. Now, .just as the 
attacks of Sidis' patient were precipitated by 
arousing the idea of coldness, of darkness, or 
of dampness, so the seizures which have de- 
veloped after traumatism may be caused, per- 
haps, to recur by means of any stimulus which 



244 Psychopathology of Hysteria 

induces the idea of injury, even though the 
patient is consciously unaware of the associa- 
tion between this idea and the consequent 
attack. 

Naturally pressure on the area which orig- 
inally was the seat of trauma is the most ef- 
fectual mode of arousing the idea of injury, or, 
by association of ideas, of provoking recurrence 
of the psycholeptic state. Such being the case 
there exist what truly may be designated 
hysterogenic zones. These zones are infrequent 
unless created by suggestion, and when they 
do exist the induction of an attack by means 
of pressure upon the zone is just as much a 
psychic phenomenon as the effects of hearing 
the words "dark, damp and cold" in Sidis' 
patient. In either case, the pressure, or the 
"hysterogenic" words, induce by subconscious 
association of ideas, repetition of the whole of 
the original mental state and precipitate a 
crisis that is identical in character with the 
original reaction unless modified by elaboration 
or by contamination through admixture with 
repetitions of the reactions of other experi- 
ences. 

If we hypnotize a subject for the first time 
and then cause some act to be performed after 
having exerted pressure upon some part of his 
body we cause an association of ideas between 
the pressure and the act. The second time that 
this subject is hypnotized pressure alone on 



Psycholepsy 245 

the same area is very apt to be followed by the 
same act that was performed during the first 
hypnotic state. The experiment is successful 
even though we have been careful to avoid 
making any verbal suggestions which would 
tend to produce the desired result. In the 
same manner it is possible to manufacture 
hypnogenic zones; in fact, these were formerly 
described, but their true significance was not 
grasped. A hypnogenic zone is the analogue 
of a hysterogenic zone, and there is nothing 
more remarkable about either of these than 
their illustration of the effects of association of 
ideas. 

But we do not have to resort to hypnosis, or 
to the hysteric, in order to observe impressive 
examples of the physical effects of association 
of ideas. Those occurring under normal cir- 
cumstances are equally wonderful. Pawlow's 
dogs, for instance, exhibited numerous in- 
stances of the effects of association of ideas 
upon the secretion of the digestive fluids. 
Merely attracting the attention of one of these 
dogs to food acted upon the secretion of saliva 
in the same manner as when it was actually 
placed in his mouth. This psychologic reflex 
could be aroused by association. Thus: "If a 
definite musical note be repeatedly sounded in 
conjunction with the exhibition of dry meat- 
powder; after a time the sound alone of the 
note is effective. Similarly with the exhibition 



246 Psychopathology of Hysteria 

of a brilliant color." (The Work of the Diges- 
tive Glands, 1910, p. 85.) 

Recurrence of hysteric crises is usually ef- 
fected through the agency of mediate associa- 
tion of ideas. As the pathogenic memory com- 
plex is dissociated from consciousness the 
hysteric remains unaware of the underlying as- 
sociation of ideas — the attacks are not accom- 
panied by conscious recollection of the original 
experience. This form of mediate association 
of ideas in itself is not abnormal. It becomes 
so only when its results are abnormal. Nor- 
mally one idea may suggest another by means 
of a third, to which both are associated, with- 
out necessitating the raising of this third idea 
above the level of consciousness. In other 
words, the association of the two ideas takes 
place through the subconscious instrumentality 
of one which is common to both. Though 
almost invariably cases of hysteria present 
manifestations which are the result of mediate 
association of ideas this form of ideation is said 
to be uncommon in normal life. 

Expectant attention may induce recurrence 
of psychoneurotic attacks. This fact has been 
the subject of grave misinterpretation. When 
a supposed epileptic announced that he would 
have a seizure at such and such an hour on a 
certain day, and when this came about just as 
he predicted, then the case was recorded as an 
instance of wonderful, or supernatural, pre- 



Psycholepsy 247 

vision. Foissac's Peter Cazot is the patient 
whose case has been most frequently cited. The 
facts of this case and the protocol of the ex- 
periment that were performed with the patient 
were included in the report to the Royal 
Academy of Paris, in 1831, of the Committee of 
Investigation of Animal Magnetism. (Quoted 
by Leger, Animal Magnetism, 1849, p. 98.) In 
commenting upon the case Leger remarked that 
notwithstanding that the patient could indi- 
cate, a month or two in advance, the day and 
hour at which he was going to have a convul- 
sion, yet he did not foresee his own death from 
an accident two days after having predicted 
the cure of his disease at a date three months 
distant. 

The explanation of the "prevision" of psy- 
choneurotic attacks, or other manifestations, is 
simple. When a psychopathic individual states 
that he will have an attack at a certain time 
his statement constitutes an autosuggestion 
which is almost sure to be carried out, and 
when the patient utters the prediction while in 
the hypnotic state, as did Peter Cazot, the auto- 
suggestion is still more forcible. 

Very often psycholeptics experience aurae 
which may be identical with those of epilepsy. 
Their origin can be discovered only by means 
of the most careful researches into the patient's 
subconsciousness, and then, no matter how 
bizarre and inexplicable they may have ap- 



248 Psychopathology of Hysteria 

peared, an adequate and perfectly reasonable 
cause will be found. The perception of any 
sensory stimulus which was experienced im- 
mediately preceding the pathogenic emotional 
casualty, or its consequent first attack, may be- 
come a constituent of the memory complex 
which has to deal with these occurrences. The 
more intense the stimulus and the more closely 
associated it was with the original experience 
the more apt is its memory to become incor- 
porated with the resultant complex. Psycho- 
leptic crises are stable — tend to recur without 
variation — therefore, before each subsequent 
attack which is caused by a direct stimulus 
the patient should experience as an aura the 
sensory impression, or impressions, which pre- 
ceded the first attack. Or, any accidental 
occurrence which recalls the memory of the 
precedent sensory perception tends to cause 
repetition of the attack which originally fol- 
lowed this perception. 

This phenomenon, too, is only an expression 
of association of ideas and it conforms closely 
to laws which have been induced. William 
James postulates as fundamental the law that 
"When two elementary brain-processes have 
been active together or in immediate succession, 
one of them, on recurring, tends to propagate 
its excitement into the other." (The Principles 
of Psychology, vol. 1, 1905, p. 566.) And ac- 
cording to Bain "Actions, sensations, and 



Psycholepsy 249 

states of feeling, occurring together or in close 
succession, tend to grow together, or cohere, in 
such a way that when any one of them is after- 
wards presented to the mind, the others are 
apt to be brought up in idea." (The Senses 
and the Intellect, 1864, p. 332.) 

A good example of the genesis of aurse is 
afforded by the case of the author Gustave 
Flaubert. The following account is that of 
Maxime Du Camp, as quoted by Grasset : 
"All at once without any apparent reason 
Gustave would throw up his head and become 
very pale. He had felt the aura. His look was 
full of anguish. He would say, 'I have a 
name in my left eye;' then a few seconds 
later, 'I have a flame in my right eye; every- 
thing seems to me to be the color of gold/ 
This singular condition would sometimes per- 
sist for several minutes. Then his visage 
would grow pale again and take on a desperate 
expression ; he would walk about rapidly ; then 
he would fairly run to his bed and stretch 
himself out on it dull and sinister as if he were 
lying alive in a coffin. Then he would cry out: 
'I have hold of the reins! Here is the carrier! 
I hear the bells ! Ah ! I see the lantern of the 
inn ! ' Then he would utter a cry whose pierc- 
ing accent still vibrates in my ears, and a con- 
vulsion would then come on. This paroxysm, 
in which his entire body trembled, was followed 
by a deep sleep and profound exhaustion 



250 Psychopathology of Hysteria 

which lasted for several days." (The Semi- 
Insane and the Semi-Responsible, trans, by 
Jelliffe, 1907.) The cause of these various 
hallucinatory antecedents of a convulsion is 
plainly made evident by the fact that the first 
attack occurred "in the neighborhood of 
Bourg-Achard, at the moment when a post- 
carrier was passing to the left of the cabriolet, 
and when on the right the lights of a lonely 
inn were perceptible in the distance." 

Parker writes of a case of psychomotor epi- 
lepsy in which the convulsions and minor at- 
tacks were preceded by a foul taste and a fetid 
odor. This aura, one which is not uncommon 
in epilepsia vera, was found, by means of hyp- 
nosis, to be due to the fact that just prior to his 
first seizure the patient had partaken of meat 
which, by reason of its offensive nature, had 
caused these perceptions. 

These cases like many others which might be 
quoted, show that the study of auras, because 
of their connection with the emotional first 
cause, is prolific of results, both in etiologic re- 
search and in therapeutic indications. 

As the consciousness of the patient is in par- 
tial or complete abeyance during all seizures, 
each psycholeptic attack, of hysteric origin at 
least, is a more or less complete somnambulistic 
state in which the patient experiences subcon- 
sciously the recurrence of some former emo- 
tional episode, usually the exciting cause of the 



Psycholepsy 251 

disease, and presents a repetition of the original 
reactions which, however, are modified by the 
pathologic elaboration and contamination to 
which they have been subjected. Indeed, the 
character of the crisis, whether convulsive or 
delirious, depends almost entirely upon the 
nature of the hallucinations, or of the delusions, 
of the patient at the time ; the objective symp- 
toms being indicative, therefore, of the mental 
state of the patient. Being somnambulistic 
states these attacks, in well developed cases 
either of psychasthenia or of hysteria, are suc- 
ceeded by amnesia for the period of their 
duration. 

Psycholeptic seizures are induced, as already 
intimated, either by conscious or by subcon- 
scious association of ideas with the conscious, 
or with the submerged, memories, of the original 
painful emotional experience, or with those of 
any antecedent sensory impression which united 
with the others to form a complex of the pri- 
mary experience. If, as an exciting cause of a 
psychoneurosis, an individual who is predis- 
posed by psychopathic heredity is subject- 
ed to a relatively severe emotional shock 
any subsequent psychic stimulus which, by 
association of ideas, recalls this experience 
thereby will tend to cause recurrence of its 
original reactions, or motor expression, in an 
elaborated and pathologic manner. In hys- 
teria the whole mechanism is more or less sub- 



252 Psychopathology of Hysteria 

conscious ; the patient usually being absolutely 
ignorant, as far as consciousness is concerned, 
of any reason for the onset of each attack. 
This fact has been explained biologically by 
assuming that, as a reaction of defense, there 
occurs voluntary suppression from conscious- 
ness of the memories of the primary experi- 
ence. 

Modern psychopathologic researches in- 
contestably have shown that what appears to 
be absolute loss of memory of the causes and 
events of each attack is, in reality, always 
functional amnesia; one which is due to disso- 
ciation or splitting off from consciousness of 
the system of memories concerning the original 
stress and each subsequent crisis, and that 
these dissociated or submerged complexes are 
preserved in subconsciousness, from which they 
can be tapped by means of association experi- 
ments, hypnoidization, hyponotization, auto- 
matic writing, analysis of reveries and dreams, 
etc. 

Though the whole mechanism of hysteric ac- 
cidents is subconscious it appears that in psy- 
chasthenia the patient is usually superficially 
aware of the causes of his symptoms. In other 
words, hysteric manifestations are caused by 
subconscious association of ideas, while those of 
psychasthenia are usually caused by conscious 
association of ideas. Furthermore, it is by 
reason of fear and expectant attention that the 



Psycholepsy 253 

crises of psychasthenia are commonly induced. 
It is important to remember, however, that the 
conscious fear and the conscious expectancy 
are purely obsessions which are originated by 
dissociated components of normal conscious- 
ness. 

In about 50-80% of those who are hypnotized 
the dissociation of consciousness is so profound 
that after being "wakened" the subject is in- 
capable of remembering consciously any of the 
events of the hypnotic state. While one of 
these hypnotic somnambulists is hypnotized 
suppose we suggest to him that when he sees 
us put on our glasses, after he is wakened, he 
will perform a certain specified act — light the 
gas, for instance. Being a somnambulist he 
does not remember this suggestion after the 
hypnotic state is dispelled; we have dissociated 
from his consciousness a certain system of ideas 
just as complexes become submerged in 
hysteria. Now, upon adjusting our glasses the 
subject is most apt to carry out the post hyp- 
notic suggestion which was imparted to him, 
without, however, knowing the true reason for 
doing so. Through the agency of subconscious 
association of ideas our stimulus arouses into 
activity the dissociated complex which, in turn, 
induces the idea of lighting the gas. Being 
ignorant of the true reason for his act he un- 
consciously substitutes some specious motive — 
a very human-like procedure — and this he will 



254 PsycJiopathology of Hysteria 

present as his reason if asked why he lighted 
the gas in view of the fact that further illu- 
mination is unnecessary. 

In this manner we have completely dupli- 
cated the psychic mechanism of a hysteric at- 
tack, and it would be just as easy to substi- 
tute convulsions for the simple act of lighting 
the gas. On the other hand, suppose our sub- 
ject is not a somnambulist — suppose that after 
being wakened he does remember the events of 
hypnosis. Then we have a mechanism which 
is similar to that of a psychasthenic manifesta- 
tion. When we put on our glasses he becomes 
obsessed with the idea of lighting the gas, but 
he is aware of the exact source of this impulse. 

To illustrate the difference between the psy- 
cholepsy of hysteria and that of psychasthenia 
let us adduce a case of each of these mala- 
dies. A male, aet. 19, was knocked from a box, 
and fell, striking his head in the occipital 
region. The injury resulted in immediate un- 
consciousness which lasted only for two or 
three minutes. Following this accident he was 
perfectly well except that he had a moderate 
headache for several hours. At this time his 
father, for whom he cared to an extent which 
was considered unusual, was acutely ill for ten 
days, and then died, after having had a con- 
vulsion. "When the patient learned of his 
father's death he was seized with severe pain 
in the head, fell unconscious, and presented the 



Psycholepsy 255 

typical manifestations of a major epileptiform 
convulsion similar to the one which had oc- 
curred in his father and of which he had re- 
ceived a graphic description. Subsequently, 
and at intervals of about a month, the seizures 
recurred; each being preceded by pain in the 
head. The later attacks, beside being char- 
acteristic otherwise of those of epilepsy, be- 
came contaminated with symptoms of hysteria. 
Being questioned he professed absolute ignor- 
ance of the cause of these crises. 

After inducing the hypnotic state it was 
demonstrated that he was perfectly cognizant 
of what was going on about him during his 
seizures, and he acknowledged that each fol- 
lowed allusions to his father, or to death, al- 
though he had been unaware of this sequence 
when in his usual state of consciousness. Dur- 
ing convulsions, thoughts of his father occupied 
his mind, and he felt that he must go to him. 
Each crisis, therefore, was a somnambulistic 
state resulting from chance occurrences which, 
by unconscious association of ideas, provoked 
the elaborated reproduction of his emotional 
reactions to the shock produced by learning of 
his father's death. The aura of his attacks — 
pain in the head — is capable of being inter- 
preted as a hallucinatory recurrence of the 
headache resulting from the fall which was so 
closely associated, in time, with his father's 
fatal illness. 



256 Psychopathology of Hysteria 

The following case is in decided and typi- 
cal contrast to the one just summarized. A 
psychasthenic male who had just had an at- 
tack which very closely simulated petit mal 
stated that prior to its onset he was not think- 
ing of himself, or of any of his symptoms, until 
a friend began to discuss a relative's death 
from heart disease. At once he was impelled 
to think of his own cardiac attacks, and, after 
a short period of fear and expectant attention, 
the symptoms appeared which were character- 
istic of one of his own seizures. This patient 
was always aware of the association of ideas 
which preceded his attacks, and he appreciated, 
in a self-condemnatory manner, the genetic in- 
fluence of his fear and expectancy. 

An intelligent psychasthenic will often ad- 
mit voluntarily that his attacks are due to the 
provocation of fear and expectancy by asso- 
ciation of ideas, and even the dispensary 
patient generally realizes, after a few words of 
explanation, that his seizures are caused in 
this manner. It appears, nevertheless, that the 
greater part of the mechanism of genesis of 
individual seizures may be subconscious in a 
few cases of psychasthenia. 

Another notable differentiating feature be- 
tween the psycholepsy of hysteria and that of 
psychasthenia is the curious fact that a hysteric 
is rarely inconvenienced or distressed by the 
occurrence of attacks, no matter how severe 



Psycholepsy 257 

or incongruous they may be, while to the psy- 
chasthenic each is characterized by the greatest 
anguish. 

For the reason that the prognosis and treat- 
ment of the psychoneuroses is necessarily so 
dissimilar from that of epilepsy a correct 
diagnosis is most essential. Another cogent 
reason for diagnostic precision is afforded by 
the incalculable amount of harm which may 
result from the psychic stress provoked by in- 
forming a hysteric, or psychasthenic, that he 
is afflicted with epilepsy; a disease which is 
looked upon with so much horror by the laity, 
and which is believed by them to be incurable 
and stigmatic. In view of these facts, then, it 
is incumbent upon us to exercise constantly 
the greatest care in order to prevent mistaking 
hysteria or psychasthenia for epilepsy, or vice 
versa. Indeed, some cases may require several 
weeks, or months, of careful study by an ex- 
pert psycho-pathologist before a definite diag- 
nosis can be made. 

As recent research has shown that epilepsy 
is incapable of causing any symptoms which 
cannot be duplicated, or at least simulated, by 
hysteria and psychasthenia, and as the crises, 
therefore, of these psychoneuroses may be 
identical with those of epilepsy, we are unable 
now to make the diagnosis epilepsy simply 
because a patient is afflicted with seizures 
which conform to the classical text-book de- 



258 Psychopathology of Hysteria 

scriptions of those which are supposed to be 
characteristic of this disease. It is only by 
careful consideration of the results of some 
psychoanalytic method which reveals the sub- 
conscious activities of the patient that we can 
differentiate, in almost a positive manner, the 
most highly developed types of hysteric and 
psychasthenic attacks from those due to 
epilepsy. In a few cases the diagnosis psycho- 
lepsy can be made positively only when the 
patient has been "cured" in a short time by 
some therapeutic measure which is effective 
only in that condition. As all of the symptoms 
of an epileptic attack can be duplicated by 
psycholepsy the basis of differential diagnosis 
may be considered from the point of view of 
the psychoneuroses. 

Psycholepsy 

1. Attacks are due either to conscious or to 
subconscious association of ideas. 

2. The attacks in a given case are always 
of a like nature unless variation occurs as the 
result of plurality of primary stresses. 

3. Prevention of attacks by means of sug- 
gestion, or of other psychotherapeutic means. 
(It seems more than improbable that a case of 
true epilepsy has ever been cured by means of 
psychotherapy alone.) 

4. Induction of attacks through the agency 
of suggestion. 



Psycholepsy 259 

5. Susceptibility of the patient to sugges- 
tion during the height of a crisis. 

6. Bromide treatment does not favorably 
influence the seizures and usually aggravates 
the other symptoms. 

7. In those cases in which the crises have 
persisted many years intelligence and memory 
do not deteriorate progressively. Amnesia, if 
present, is purely functional in character, and 
events which apparently have been forgotten 
are capable of being recovered by means of 
hypnosis and certain other well known pro- 
cedures. 

8. The discovery, through some psychoan- 
alytic method, of a wealth of pathogenic and 
dissociated, or subconscious ideation. 

9. Conservation in subconsciousness of the 
memories of events which occurred during 
seizures. Demonstration of this conservation 
of memories by causing reproduction through 
the agency of methods which have already been 
mentioned. 

It is to be hoped that some competent inves- 
tigators who possess the requisite opportunities 
will interest themselves in researches having 
as their end the corroboration of what theoreti- 
cally has been assumed, and to a certain extent 
demonstrated : that in epileptics it is impossible 
by any known means to recover memories of 
events which happened during the height of a 



260 Psychopathology of Hysteria 

convulsion. The recovery of such memories 
may be accepted, however, as unimpeachable 
evidence of the psychogenic nature of a con- 
vulsion; no matter how typical otherwise of 
epilepsy it may have seemed. This statement 
may appear to be too conclusive, but in all the 
literature at my command I have been unable 
to discover any case of undoubted epilepsy in 
which the memories of events which occurred 
during attacks were successfully reproduced, 
and, on the other hand, investigators who have 
succeeded in reproducing such memories in 
supposed cases of epilepsy unite in saying that 
the cases have always turned out to be ones of 
psycholepsy. 

Inasmuch as the existence either of epilepsy 
or of psychoneuroses in the progenitors may 
cause the development, in the offspring, of any 
of the conditions under discussion, the dis- 
covery of neuropathic heredity is not of great 
importance in the differential diagnosis of 
epilepsy, hysteria, and psychasthenia. 

When in doubt as to the cause of convulsions 
it is Bernheim's custom to press upon the 
abdomen, or other region in which the aura 
commences, while making the suggestion that 
the pressure will be painful ; then that the globe 
rises in the throat, and that the patient feels 
her crisis approaching. In this manner he 
creates a hysterogenic zone and causes the 
onset of an attack. In the great majority of 



Psycholepsy 261 

cases, he affirms, the crises are capable of being 
provoked experimentally by this means, and 
without the induction of the hypnotic state. 
Having succeeded in reproducing the crisis he 
considers that the diagnosis hysteria is con- 
firmed, and that the condition is curable. 
(Hypnotisme et Suggestion Hysterie Psy- 
ehonevroses, 1910, p. 255.) 

The knowledge possessed by epileptics that 
they are afflicted with an incurable organic 
nervous disease; the severity of the symptoms 
of this disease; and the unexpected manner in 
which old symptoms may recur, or new ones 
suddenly appear, together with the state of 
fear and expectant attention which thereby 
is ultimately provoked, often leads to the de- 
velopment of a superimposed psychoneurosis. 
Consequently, the fact that a patient presents 
the hysteric or psychasthenic type of tempera- 
ment, in addition to the discovery of 
''stigmata" of either of these conditions, does 
not necessarily eliminate the possibility of the 
coexistence of epilepsy. As a matter of fact it 
is not at all unusual for epileptic and psy- 
choleptic seizures to alternate. 

As to the prognosis of psycholepsy and of 
other psychogenetic seizures : When the at- 
tacks occur in cases of hysteria the results of 
treatment are excellent, and a symptomatic 
cure is to be expected in all cases. It is 
singular, indeed, that one of the most severe of 



262 Psychopathology of Hysteria 

the major symptoms should be so amenable to 
treatment. In my own experience it has re- 
quired only a few weeks to overcome the 
psycholeptic habit of about 95% of hysteric 
patients and in the majority of these the 
seizures have failed to recur after the first 
treatment. Bernheim writes: "After an ex- 
perience of 20 years, I affirm that, except those 
confirmed cases in whom the hysterogenic 
automatism has become, so to speak, a cerebral 
localization, the crises always can be perman- 
ently dissipated, formerly I said by hypnotic 
suggestion; to-day I say by education of the 
will of the patient." (Conception Du Mot 
Hysterie, 1904, p. 8.) 

If the attacks are symptomatic of psychas- 
thenia the results, though good, are not so 
favorable as those obtained in hysteria. The 
difference in the prognosis of these two diseases 
is readily comprehended by taking into consid- 
eration the difference in the mental states char- 
acteristic of the two conditions. Cases of 
hysteria are eminently suitable for the appli- 
cation of psychotherapy because the proper 
suggestions are more apt to be accepted un- 
critically and without any resistance. Unfor- 
tunately, in psychasthenia the hypnotic state is 
usually secured with difficulty because of the 
inability of the patient to concentrate his at- 
tention by reason of the distracting influence 
of fear and of extraneous ideas. More or less 



Psycholepsy 263 

unconscious and antagonistic autosuggestion 
also interferes greatly, in these cases, both with 
the production of the hypnotic state, and with 
the acceptance of therapeutic suggestions after 
this state is secured. In response to each sug- 
gestion of the physician the patient seems im- 
pelled to expect the contrary to occur. If 
psychotherapy is adopted without attempting 
to induce hypnosis the same difficulties are en- 
countered, but then they are more troublesome. 
The manner in which the attacks of hysteria 
should be treated is rendered evident by pos- 
sessing knowledge of the psychic mechanism of 
the conditions which may cause this clinical 
phenomenon. If, for example, a certain stim- 
ulus, or a certain kind of stimuli, is found to 
cause recurrence of the aura, either by con- 
scious or by subconscious association of ideas, 
and thereby to precipitate a crisis, then one of 
the first principles of treatment is to abolish 
this tendency. The same applies to reproduc- 
tion of seizures by either form of association of 
ideas with any other component of the dormant 
complex. To do this in a scientific, effective 
and lasting manner requires synthesis with the 
patient's consciousness of the dissociated and 
pathogenic complexes. Naturally this proce- 
dure necessitates discovery, by means of some 
psychoanalytic method, of the submerged com- 
plexes, and then their reintegration with con- 
sciousness by means of inducing the patient 



264 Psychopathology of Hysteria 

consciously to remember the original painful 
experience and its emotional consequences. 

Even though at first it may seem highly im- 
probable that a patient may be cured of certain 
nervous manifestations by causing him to recall 
some painful episode in his life, it is, neverthe- 
less, a fact which is quite generally known. 
In writing of this peculiarity, as it occurs in 
hysteria, Freud remarks : ' ' We found, at first 
to our greatest surprise, that the individual 
hysterical symptoms immediately disappeared 
without returning if we succeeded in thoroughly 
awakening the memories of the causal process 
with its accompanying effect, and if the patient 
circumstantially discussed the process giving 
free play to the effect." (Selected Papers on 
Hysteria, Trans, by A. A. Brill, 1909, p. 4.) 

Let us see how Bernheim treats with simple 
suggestion his psycholeptic patients. Having 
succeeded in reproducing a crisis, he affirms 
positively before the patient and his students 
that cure is certain. Whether he has produced 
the crisis himself, or he is called upon to treat 
one which has appeared spontaneously, he 
dissipates the attack, usually within three 
minutes, by suggesting progressively the dis- 
appearance of the various symptoms. After he 
has provoked a crisis and then dissipated it, 
he commences to re-educate the patient in order 
to teach her to inhibit the seizures. His 
method of suggestion is to say to the patient : 



Psycholepsy 265 

"You see that I have been able to bring on a 
seizure and to stop it. I can also prevent you 
from having them. To prove it I will now press 
on the same spot where pressure provoked an 
attack a little while ago, and this time the 
crisis will not appear. You will feel, perhaps, 
as if one was about to appear; but it will not 
do so." At first he touches lightly, and then 
gradually increases the pressure upon the 
region which had been rendered hysterogenic. 
Often the patient becomes excited ; her respira- 
tion becomes panting; she feels the globus 
hystericus; the crisis is imminent. He smiles, 
however, and reassures her by saying: "Calm 
yourself; the attack will not come. You will 
remain master of yourself.'' This suggestive 
lesson is repeated every day, and it is rare, he 
asserts, that cure is not obtained in three days. 
His object is to teach the patient to control her- 
self and to restore to her the confidence in her- 
self which she has lost. (Hypnotisme & Sug- 
gestion, 1910, p. 255). 

There are certain only too popular forms of 
treatment of hysteric attacks which cannot 
be condemned too strongly. Many hospital 
internes inject apomorphine into every hysteric 
that comes into the receiving ward during a 
seizure. No doubt this procedure is very effica- 
cious; the attack coming to a sudden termina- 
tion with the onset of vomiting. But, one 
would have just as good reason to apply the 



266 Psychopathology of Hysteria 

same treatment to a child because it cries. Be- 
side the fact that recurrence of seizures is not 
prevented by forcible suppression, particularly 
by a punitive measure — for that is what hypo- 
dermic injection of apomorphine may be con- 
sidered to be when used in the treatment of 
hysteria — the treatment is decidedly harmful. 
By reason of the suggestibility which is char- 
acteristic of hysteria, it is not at all improb- 
able that many cases that have been treated 
in this manner present vomiting as a feature of 
subsequent attacks. 

Some authors advise inhalations of ether or 
of chloroform in the treatment of severe hys- 
teric attacks. Such measures must be effec- 
tive, but they certainly should increase the 
resistance of the disease to subsequent treat- 
ment, and they remind one of the man who 
resorted to a sledge hammer in order to kill a 
flea. The administration of morphine is espe- 
cially pernicious. Not only is such treatment 
merely palliative of the immediate attack but 
it establishes a harmful precedent, which may 
be followed by development of a drug habit. 
Bromides, too, are injurious, in that they have 
a depressing effect when administered in large 
doses, and they tend to produce a stuporous 
condition which may become elaborated into 
a variety of hysteric manifestations. More- 
over, these drugs do not have any effect upon 
the convulsive habit. Valerian, asafoetida and 



Psycholepsy 267 

the like are not detrimental; neither are they 
beneficial, save by reason of the fact that their 
peculiarly offensive odor may lead the patient 
to believe that she is taking some powerful 
drug which may cure her. One well-known 
authority advises a restraining sheet or a 
straight- jacket in order to control patients with 
severe convulsions ! 



CHAPTER VIII 

Alterations of Consciousness 



M 



ORBID Somnolent States and Nar- 
colepsy. Morbid somnolence consists 
in a prolonged sleep-like state, while 
narcolepsy is characterized by periods 
of sudden irresistible inclination to sleep which 
may occur at any time, regardless of the sur- 
roundings of the patient and of what he is do- 
ing at the moment. The majority of cases of 
narcolepsy have probably been due to organic 
disease. Inasmuch as experimental investigation 
has resulted in reasonable doubt concerning the 
existence of psychic epilepsy, it is possible, also, 
that what is supposed to be epileptic narcolepsy 
is really a manifestation of hysteria. All of the 
few cases of typical narcolepsy that have come 
under my observation have been due to hys- 
teria. One patient, a known hysteric, devel- 
oped narcoleptic seizures that occurred fre- 
quently during the day and which caused her 
to go to sleep even while working around 
machinery that might have injured her, and 
even though, on account of her infirmity, she 
was in danger of losing her position. Besides 
other features of the case, the fact that several 
treatments with hypnotic suggestion effected a 
cure is sufficient evidence for the exclusion of 
organic disease. During sixteen years Weisen- 

268 



Alterations of Consciousness 269 

burg's patient had been subject to frequent 
attacks of morbid somnolence that occurred at 
any hour of the day. She had been known even 
to sleep while standing. In spite of the long 
duration of the affection, the patient was being 
rapidly cured by psychotherapy. (Jour, of 
Nerv. and Ment. Dis., 1909, p. 367). 

There is no reason for looking upon func- 
tional narcolepsy with a degree of surprise and 
wonderment greater than we bestow upon psy- 
cholepsy and its mode of genesis. The mechan- 
ism is the same in each, and the manifestations 
of convulsive seizures differ from those of the 
narcoleptic attacks of hysteria only in that 
the former include various psychomotor phe- 
nomena in addition to a subconscious state, 
Objectively, hysteric narcolepsy represents 
only the fixation of a lapse of consciousness, 
while in the case of hysterogenic convulsions 
the primary emotional reaction is repeated 
more or less completely, and, during the course 
of repetition, perhaps becomes developed and 
expanded. For instance, as a reaction to some 
disagreeable experience a hysteric faints. 
Subsequently a state of hysteric narcolepsy is 
induced by casual references to this event, or 
by any stimuli which by subconscious associa- 
tion of ideas arouse into activity the submerged 
complex of the occurrence. 

That psychologic gold mine, the Beauchamp 
case, furnishes a particularly fine instance of 



270 Psychopathology of Hysteria 

trance-like states brought about by association 
of ideas with the memories of sensory percep- 
tions which were contemporaneous with the 
onset of a syncopal attack. While preparing to 
retire, Miss B. had fallen into a trance. Believ- 
ing that pathologic association of ideas was the 
cause of this occurrence, Prince inquired into 
the matter. The result of his investigations 
was as follows: "Just before going into the 
trance she found herself thinking of an old 
girl friend. How she came to be thinking of 
this friend she did not know, but this girl once 
gave her a severe nervous shock, and she has 
noticed that the occasion of going into trances 
of late years almost always has been while 
thinking of this girl, or while hearing certain 
music, or the sound of the wind, or while feel- 
ing the air blowing on her face, and other 
sensations, all of which are associated with 
this friend.' ' 

"It came about originally in this way: A 
long time ago, while in church and while the 
organist was playing the Hallelujah Chorus 
from Handel's Oratorio, this friend leaned to- 
wards her and told her something that gave her 
a severe shock, — much as if she had told her 
the news of someone 's death. At the same time 
she smelled the odor of incense in the church, 
heard the wind blowing through the open win- 
dow, and felt it on her face. All this she was 
distinctly conscious of at the time, as well as 



Alterations of Consciousness 271 

of the nervous shock. Then she remembered 
nothing more for a few minutes. Now any- 
thing that recalls this girl, or the scene in the 
church to her mind, — such as the Hallelujah 
Chorus, the smell of incense, the sound of the 
wind, or the wind blowing on her face, — is apt 
to send her into a trance." (The Dissociation 
of a Personality, 1906, p. 88). 

A typical example of the manner in which 
individual attacks may be reproduced as the 
effect of association of ideas is furnished by 
some incidents directly resulting from the 
faulty methods of hypnosigenesis formerly 
employed at the Salpetriere. In this institution 
hysteric patients were customarily hypnotized 
by means of intense sensorial excitation; a 
flash of bright light, the sound of a gong, etc., 
being employed. After having been discharged 
from the hospital more than one patient has 
developed a lethargic or cataleptic state as the 
consequence of a sudden flash of light, — such 
as would be produced by the reflection of the 
sun from a window, — or from hearing a gong 
whose sound was like that of the one which 
formerly had been used for the purpose of 
inducing hypnosis. Here, then, is a true 
lethargic or cataleptic state which has been 
originated as a clinical artefact, and which, 
per se, cannot be differentiated from one that 
occurs as an actual manifestation of hysteria. 
When originating accidentally in the above 



272 Psychopathology of Hysteria 

manner, these states are comparable with the 
anaesthesias of medical origin; both are for- 
tuitous manifestations of the increased sug- 
gestibility that is characteristic of hysteria. 

When cataleptic rigidity accompanies morbid 
somnolence the condition is designated catalepsy. 
By means of hypnotic suggestion cataleptic 
rigidity can be produced in almost all subjects. 
Given one in whom a somnolent state, with or 
without catalepsy, has been effected by this 
means, it would be impossible for a second phy- 
sician positively to differentiate the condition 
itself from one which had resulted as a mani- 
festation of hysteria. In fact, the trance-like 
states of hysteria in many respects are auto- 
hypnotic in nature. 

An obstinate case of catalepsy was reported 
by Core. (Lancet, June 19, 1909.) Following 
his sixth epileptiform attack a boy developed 
somnolence with muscular rigidity. Soon after 
the onset of this state food that was placed in 
his mouth no longer was swallowed, but after 
feeding him once through a nasal tube no further 
difficulty was experienced in this respect. Gen- 
eral contractures appeared after the tenth week. 
During the sixteen weeks that the lethargy con- 
tinued he did not make any voluntary movements 
except of frowning and of withdrawal from 
painful stimuli, and except that his eyes re- 
mained open and he watched the actions of those 
around him. Several times, too, he shouted dur- 



Alterations of Consciousness 273 

ing galvanization. Involuntary urination was 
persistent. Without discoverable cause rapid 
recovery set in after the condition had continued 
sixteen weeks. 

It is interesting that cataleptic states, like 
psycholepsy and many other manifestations of 
hysteria, are found even among savages and the 
partially civilized. In connection with the epi- 
demic of religious hysteria that attended the 
dissemination of the ghost-dance religion, Major 
MacMurray writes of the Indian Smoholla : ' ' He 
falls into trances and lies rigid for considerable 
periods. Unbelievers have experimented by 
sticking needles through his flesh, cutting him 
with knives, and otherwise testing his sensibility 
to pain, without provoking any responsive action. 
It was asserted that he was surely dead, because 
blood did not flow from the wounds." (Four- 
teenth Annual Eeport of the Bureau of Eth- 
nology, Smithsonian Institute, part 2, p. 719.) 

Similar to the induction of hallucinations and 
delusions by suggestion, and also the ability of 
the subject to talk about these experiences dur- 
ing the hypnotic state or after it has been dis- 
pelled, is the occurrence of like phenomena dur- 
ing some of the trance states of hysteria. As a 
product of the religious fervor of the Middle 
Ages, and less frequently even at present, 
hysteria often manifested itself in the produc- 
tion of what is called ecstasy ; a state in which a 
deviation from the patient's usual state of con- 



274 Psychopathology of Hysteria 

sciousness is accompanied by the occurrence of 
hallucinatory revelations of a religious type. 

Just as autosuggestion is such a powerful 
factor in the genesis of individual symptoms of 
hysteria, so it is influential in determining both 
the onset of such trances and the character of 
the revelations. Consequently, those who ex- 
pected to be favored with heavenly revelations 
were subject to delusions or hallucinations of 
this nature, while other unfortunate religieuses 
who believed that they were possessed, and who 
anticipated intercourse with the devil, actually 
vociferated the occurrence of such proceedings 
during or after their trances. As a result of the 
religious enlightenment of modern times ecstasy 
has disappeared as a religious phenomenon only 
to become debased into being a valuable asset to 
the spiritualistic medium who is enabled, through 
the agency of autosuggestion, to bring about 
trance-like states during which she presumes to 
reveal the future, consult with the spirit world, 
and what not. 

The most wonderful feature of prolonged 
hysteric somnolence is the absolute negativism of 
a non-insane individual who passes what may be 
a great portion of a life time in what to all 
intents is an ideational sleep. What is more 
remarkable than the extent of inhibition that is 
exercised by such patients in reference to the 
countless ways in which their condition may 
affect loved ones; which renders them prisoners 



Alterations of Consciousness 275 

upon a bed; which is capable of reducing their 
consciousness to a state that is neither life nor 
death ; which causes them to be little better than 
vegetating organisms? Indeed, the feats of 
endurance and of perverse and intense applica- 
tion of volition that are encountered in cases of 
hysteria are more comprehensible when one con- 
siders the power of morbid ideation to produce 
such a state of somnolence. 

One of the most extraordinary cases of pro- 
longed somnolence is that reported by Lancer- 
eaux. (La Semaine Med., No. 10, 1904.) The 
somnolence of this patient developed with con- 
vulsions and general contractures after she had 
been subjected to intense emotional excitement 
at the age of 22 years. After having continued 
twenty years, uninterrupted except during con- 
vulsions, the lethargic state disappeared soon 
before death from phthisis. With the return of 
consciousness it was found that the patient was 
amnesic for the whole period of somnolence. In 
Oettinger's case (Jour, of Nerv. and Ment. Dis., 
1908, p. 129) catheterization and enemata were 
necessary during a third attack of somnolence 
that lasted 35 days. Apomorphine and pressure 
on the supraorbital nerve failed to arouse him. 
Five days after the adoption of treatment with 
cold baths the somnolent condition disappeared. 

The citation by Macnish (The Philosophy of 
Sleep, 1840, p. 245) of a case of periodic morbid 
somnolence that presumably was due to hysteria 



276 Psychopathology of Hysteria 

is interesting because of the dependence of part 
of the attacks upon the varying occurrence, 
in time, of daybreak. Even more interesting 
would have been the results of a modern psycho- 
analysis having as one of its objects the deter- 
mination of the cause of the relation between the 
attacks and daybreak. ' ' One of the most extra- 
ordinary instances of excessive sleep," he writes, 
"is that of the Lady of Nismes, published in 
1777, in the 'Memoirs of the Royal Academy of 
Sciences at Berlin.' Her attacks of sleep took 
place periodically, at sunrise and about noon. 
The first continued till within a short time of the 
accession of the second, and the second till be- 
tween seven and eight in the evening — when she 
awoke and continued so till the next sunrise. 
The most extraordinary fact connected with this 
case is, that the first attack commenced always 
at daybreak, whatever might be the season of 
the year, and the other always immediately after 
twelve o'clock. During the brief interval of 
wakefulness which ensued shortly before noon, 
she took a little broth, which she had only time 
to do, when the second attack returned upon 
her, and kept her asleep till the evening. Her 
sleep was remarkably profound, and had all the 
characters of complete insensibility, with the 
exception of a feeble respiration, and a weak but 
regular movement of the pulse. The most sin- 
gular fact connected with her remains to be 
mentioned. When the disorder had lasted six 



Alterations of Consciousness 277 

months, and then ceased, she had an interval of 
perfect health for the same length of time. When 
it lasted one year, the subsequent interval was 
of equal duration. The affection at last wore 
gradually away; and she lived, entirely free of 
it, for many years after. She died in the eighty- 
first year of her age, of dropsy, a complaint 
which had no connection with her preceding 
disorder. ' ' 

The recognition of cases of hysteric somno- 
lence should not be difficult. The stuporous con- 
dition of the patient is more apparent than real, 
for no matter how profound the state may be 
there remain traces of awareness of environ- 
ment that can be detected by close observation. 
The closed eyelids may present a fine tremor 
like the familiar one which is seen when a 
hysteric is told to close her eyes during the 
course of a neurologic examination. 

The qualities of the mental states which accom- 
pany hysteric morbid somnolence are identical 
with those of hypnosis ; with either condition the 
states are ones of dissociation that vary in nature 
according to the individual, and which are char- 
acterized by inhibition of the conscious mental 
faculties with consequent emancipation of sub- 
consciousness. The patient is not unconscious; 
she is aware of her surroundings in the same 
manner that a case of hysteric amaurosis per- 
ceives visual stimuli. No matter how deep the 
state of apparent coma may seem the patient 



278 Psychopathology of Hysteria 

hears and understands all that is said around 
her, and for this reason care must be exercised 
in order not to make any remarks that one would 
not utter were the patient in her usual condi- 
tion, and especially to avoid creating new mani- 
festations, or increasing the severity of those 
already existing, by reason of discussing in her 
presence the symptoms which she has or those 
that might develop. 

If we hypnotize someone and then remark to 
a third person that the subject's arm is power- 
less, in most instances an ideational paralysis 
actually develops without further suggestion. 
Or, the hypnotic state can be dispelled by 
making in the same indirect manner the re- 
mark that the subject is waking. To a less 
degree the same tendency exists in patients 
with hysteric morbid somnolence. Instead, 
perhaps, of making indiscreet remarks and 
thus aggravating the condition we can take 
advantage of this suggestibility, and, by veil- 
ing our suggestions, convey to the patient ideas 
which are favorable to recovery, without, how- 
ever, allowing her to perceive that such is our 
intention. 

Just as one who has been hypnotized may 
or may not remember the events of the 
hypnotic state so the memory of a patient who 
has recovered from hysteric somnolence may 
or may not be deficient. In order to prove 
that patients who have recovered from leth- 



Alterations of Consciousness 279 

argic, narcoleptic, and cataleptic states, were 
really cognizant of what happened around 
them, and in order to demonstrate that the 
memories of these occurrences are not lost, 
but only dormant, it suffices to tap the pa- 
tient's subconsciousness. There are numer- 
ous methods of doing so. The most important 
of these are hypnotization, hypnoidization, 
free association, reaction time experiments, au- 
tomatic writing, crystal vision, and suggestion 
in the waking state. 

Let us see what Janet has written concern- 
ing the mental state during hysteric som- 
nolence: "I do not think that in these indi- 
viduals the psychological phenomena have dis- 
appeared; I do not think that their sleep is a 
merely physical phenomenon. By many methods 
one can prove the existence of thoughts that 
continue to develop in their minds. First of 
all, a protracted and attentive observation very 
often shows you slight signs connected with 
thoughts. There are a few little movements 
of the lips, as if the subject wanted to speak, 
or sometimes smile, a few little transient ex- 
pressions of the physiognomy, a few little 
movements of the hands. In certain cases, you 
have quite the impression that the patient 
chatters inwardly, and that but little is wanting 
for you to be able to understand him. By 
means of certain processes which we cannot 
study in detail, one can sometimes put one's 



280 Psychopathology of Hysteria 

self in relation with such subjects; by merely 
touching them, speaking to them, it is possible 
to attract their attention, and then one can 
question them and obtain certain answers. 
Sometimes, in the most favorable cases, the 
subject will answer by speaking; sometimes he 
will answer by slight signs of the fingers or 
face. If you take his hand and ask him to 
press it in order to say 'yes/ sometimes you 
obtain nothing but movements of the eyelids 
and eyebrows: a slight lowering of the eye- 
brows will mean 'yes,' their rising will mean 
'no. ' And you can thus penetrate a little into 
his thought. Lastly, in other and more fre- 
quent cases, you will be able, after the crisis 
of sleep, to find again the recollection of it in 
states of artificially provoked somnambulism, 
about which I shall tell you a few words at the 
end of this lesson. ' ' 

"By using these various means, you can 
ascertain that the immobility of such patients 
is much less physical than moral. Some have 
in their mind the fixed idea of sleep or death, 
and they realize outwardly the attitude they 
are thinking of. But many others have ideas 
that are not in the least connected with the 
sleep. They are seized with a profound r every, 
in which they contemplate scenes that present 
themselves before them, or indulge in an end- 
less inward chattering. A girl of sixteen, who 
has been terrified by a bull coming to attack 



Alterations of Consciousness 281 

her, has crises of sleep, with perfect immobility, 
during which she is appalled by the hallucina- 
tion of the bull. Another, aged thirty-two, in 
despair at the death of a friend, relates to her- 
self dismal stories about her own death : ' They 
are going to put candles near my bed ; they are 
putting me in a little deal coffin; my friends 
are bringing white flowers to put on my little 

coffin, which is there, placed on two chairs ' 

and she talks thus endlessly. A man of twenty- 
five has been much upset by an accusation 
brought against him by a fellow-workman. 
When he meets with this individual, he be- 
comes motionless, like one petrified, and at 
last he slips to the ground and lies, as if asleep, 
for hours together, talking inwardly about the 
accusation brought against him. He fancies he 
is before his employer, and defends himself in 
every way, arguing in a complicated manner 
as if he were before a court of- justice." 
(Major Symptoms of Hysteria, 1906, p. 106.) 

The treatment of the various kinds of altera- 
tions of consciousness is the same as that of 
psycholepsy: discovery and removal of the 
psychic causes of the seizures and recovery of 
dissociated memories together with fusion of 
these with the conscious personality of the 
patient. 

Insomnia, the opposite of morbid som- 
nolence, is frequent in hysteria. A peculiarity 
of the human mind is to exaggerate the dura- 



282 Psychopathology of Hysteria 

tion of interruptions of sleep, or to overestimate 
the length of time before sleep appears after it 
is sought. How frequent it is to read on the 
nurse's report: ''Patient slept well the whole 
night," and then to have the non-neurotic pa- 
tient assert that he had passed a sleepless 
night ! Even more bitterly do psychoneurotics 
complain of losing most of their sleep, or of not 
having slept at all when, in reality, such has 
not been the case. Uncommonly, the patient 
actually does not sleep, but there is sufficient 
mental and physical relaxation to prevent ex- 
haustion, even though the difficulty may per- 
sist indefinitely. In some of these cases in- 
somnia is the most prominent, or apparently 
even the only symptom of the disease, and it 
may be resistant to treatment. Usually, how- 
ever, little difficulty is experienced in enabling 
the patient to sleep in a normal manner. 

Somnambulism. — Without the participation 
of consciousness psychomotor activity that is 
adapted to some definite end, and which va- 
ries according to environmental influences, is 
known as somnambulism. Such a definition is 
most inclusive: so also has been the use of the 
appellation. The states of massive dissociation 
induced by hypnotic suggestion and which are 
characterized by the possibility of production 
by suggestion of psychomotor automatism with 
subsequent amnesia, have been designated states 
of hypnotic somnambulism. Sleep walking is 



Alterations of Consciousness 283 

called nocturnal, or spontaneous, somnambulism, 
while various kinds of hysteric ambulatory auto- 
matism, whether nocturnal or diurnal, have been 
included under the term hysteric somnambulism. 
The distinctiveness of the name has been still 
further degraded by making it embrace the va- 
rious attacks of hysteria. It seems best to limit 
the term morbid somnolence to a state of disso- 
ciation that is manifested by a more or less pro- 
longed sleep-like condition; narcolepsy to peri- 
odic sleep-like seizures of short duration; som- 
nambulism to a state of dissociation which is 
characterized by monoideic psychomotor auto- 
matism; ambulatory automatism and fugues to 
more highly developed dissociation in which, 
though the usual state of consciousness of the 
patient is in abeyance, neither his actions nor 
his mental state may appear abnormal to stran- 
gers ; and multiple personality to the completely 
developed type of dissociation that results in the 
production of two or more distinct personalities. 
These limitations imply merely an arbitrary 
division of a scale of dissociation whose intensity 
varies by imperceptible gradations. 

There is no good reason why the term noc- 
turnal somnambulism should not include all 
kinds of motor expression of organized ideation 
that may occur during sleep, whether this be by 
walking or even by talking. An individual is 
not in a state of normal sleep when he gives 
verbal expression to subconscious ideation. That 



284 



Psychopathology of Hysteria 



actual walking does not occur in such cases may 
be dependent merely upon the character of the 
underlying ideation, and a person who talks one 
night during sleep on another occasion may walk 
around and perform complex acts during the 
same kind of state. In the first case he may 
be engaged in conversation with a hallucinated 
person and other forms of activity may not be 
required. In the second instance he is acting 
logically in accordance with the necessity im- 
posed by subconscious ideas which happen to 
arise. One of Macnish's cases of sleep-walking is 
a good example of motor automatism dependent 
upon a dream: "I knew a gentleman who, in 
consequence of dreaming that the home was 
broken into by thieves, got out of bed, dropped 
from the window (fortunately a low one) into 
the street ; and was a considerable distance on his 
way to warn the police, when he was discovered 
by one of them, who awoke him, and conducted 
him home." (The Philosophy of Sleep, p. 196.) 
It is customary to speak of the motor auto- 
matisms of spontaneous somnambulism, but 
each of these is accompanied with sensory auto- 
matism. Not only does the sleep-walking in- 
dividual present motor activity, but subcon- 
scious sensory perception takes place; other- 
wise, walking would be impossible and the per- 
formance of complicated acts out of the ques- 
tion. By reason of the character of the pa- 
tient's utterances delusions and hallucinations 



Alterations of Consciousness 285 

are evident. Their existence and their nature 
can be proven through the agency of psychoan- 
alytic procedures. 

Jn the absence of fever, toxic states and or- 
ganic disease, persons who are accustomed to 
exhibit nocturnal somnambulism thereby dis- 
play so strong a tendency towards dissociation 
that it seems reasonable to conclude either that 
indubitable evidences of hysteria would be 
found were careful investigation instituted, or 
that the disease otherwise is latent. In other 
words, all well developed cases of functional 
spontaneous somnambulism are probably hys- 
teric in origin. As expressed by v. Bechterew 
(Jour, of Abnormal Psychology, vol. 1, p. 25.) 
walking and talking during sleep are manifesta- 
tions which pass the limits of the normal and 
approach closely certain neurotic states. 

Clinical experience shows that but few cases 
of nocturnal somnambulism occur in the ab- 
sence of obvious symptoms of hysteria, and 
that in these exceptions the presence of exag- 
gerated suggestibility and of emotionalism is 
decidedly significant. Conversely, with adult 
hysterics it is exceedingly common to elicit a 
history of repeated talking and walking during 
sleep. Just as all symptoms of hysteria are 
probably only exaggerations or perversions of 
the normal, and for the same reason that all 
states of dissociation are not necessarily patho- 
logic, so it would be inadvisable to regard as 



286 Psychopathology of Hysteria 

hysteric isolated instances of the utterance of a 
few words during- sleep. 

Both the mental states and the phenomena 
that occur during nocturnal somnambulism are 
duplicated by those which arise spontaneously 
in the course of some cases of hysteria, and 
which are capable of artificial production with 
hypnotic suggestion. Tn each of these condi- 
tions hallucinations and systematized negative 
hallucinations may occur. Personal perception 
is limited to what the ideation of the moment 
necessitates ; other perceptions not being syn- 
thetized with the state of consciousness which 
is uppermost at the time. Hence the ordinary 
somnambulist does not pay any attention to 
those whom he many encounter, unless, in case 
of nocturnal somnambiilism at least, their efforts 
are sufficiently strenuous to " awaken" him. 

Hammond was fortunate enough to have the 
opportunity of examining a patient during 
the course of what evidently was an attack 
of hysteric somnambulism, though he does not 
express any opinion of its nature. "A young 
lady," he writes, "of great personal attrac- 
tions, had the misfortune to lose her mother 
by death from cholera. Several other mem- 
bers of the family suffered from the disease, 
she alone escaping, though almost worn out 
with fatigue, excitement, and grief. A year 
after these events, her father removed from 
the "West to New York, bringing her with him 



Alterations of Consciousness 287 

and putting her at the head of his household. 
She had not been long in New York, before she 
became affected with symptoms resembling those 
met with in cholera. The muscles of the face 
were in almost constant action, and though she 
had not altogether lost the power to control 
them by her will, it was difficult for her at 
times to do so. She soon began to talk in 
her sleep, and finally was found one night 
by her father, as he came home, endeavoring to 
open the street-door. She was then, as he said, 
sound asleep, and had to be violently shaken to 
be aroused. After this she made the attempt 
every night to get out of bed, but was generally 
prevented by a nurse who slept in the same 
room with her, and who was awakened by the 
noise she made in the room." 

"Her father now consulted me in regard to 
the case, and invited me to the house in order 
to witness the somnambulic acts for myself. One 
night, therefore, I went to his residence and 
waited for the expected manifestations. The 
nurse had received orders not to interfere with 
her charge on this occasion, unless it was evi- 
dent that injury would result, and to notify 
us of the beginning of the performance." 

"About twelve o'clock she came down stairs 
and informed us that the young lady had risen 
from her bed and was about to dress herself. 
I went up stairs, accompanied by her father, 
and met her in the upper hall partly dressed. 



5 



288 Psychopathology of Hysteria 

She was walking very slowly and deliberately, 
her head elevated, her eyes open, her lips un- 
closed, and her hands hanging loosely by her 
side. We stood aside to let her pass. Without 
noticing us, she descended the stairs to the 
parlor, we following her. Taking a match, 
which she had brought with her from her own 
room, she rubbed it several times on the under 
side of the marble mantelpiece until it caught 
fire, and then, turning on the gas, lit it. She 
next threw herself into an armchair and look- 
ing fixedly towards a portrait of her mother 
which hung over the mantelpiece. While she 
was in this position, T carefully examined her 
countenance, and performed several experi- 
ments with the view of ascertaining the con- 
dition of the senses as to activity.' ' 

' ' She was very pale, more so than was natural 
to her; her eyes were wide open and did not 
wink when the hand was brought suddenly in 
close proximity to them ; the muscles of the face, 
which when she was awake were almost con- 
stantly in action, were now perfectly still; her 
pulse was regular in rhythm and force, and 
beat 82 per minute, and the respiration was uni- 
form and slow." 

' ' I held a large book between her eyes and the 
picture she was apparently looking at, so that 
she could not possibly see it. She nevertheless 
continued to gaze in the same direction as if no 
obstacle were interposed. I then made several 



Alterations of Consciousness 289 

motions as if about to strike her in the face. She 
made no attempt to ward off the blows, nor did 
she give the slightest sign that she saw my 
actions. I touched the cornea of each eye with 
a lead-pencil I had in my hand, but even this 
did not make her close her eyelids. I was en- 
tirely satisfied that she did not see — at least with 
her eyes." 

"I held a lighted sulphur-match under her 
nose, so that she could not avoid inhaling the 
sulphurous acid gas which escaped. She gave 
no evidence of feeling any irritation. Cologne 
and other perfumes, and smelling-salts likewise 
failed to make any obvious impression on her 
olfactory nerves." 

' ' Through her partially opened mouth, I intro- 
duced a piece of bread soaked in lemon-juice. 
She evidently failed to perceive the sour taste. 
Another piece of bread, saturated with a solution 
of quinine, was equally ineffectual. The two 
pieces of bread remained in her mouth for a full 
minute, and were then chewed and swallowed. ' ' 

"She now arose from her chair and began to 
pace the room in an agitated manner ; she wrung 
her hands, sobbed, and wept violently. While 
she was acting in this way, I struck two books 
together several times so as to make loud noises 
close to her ears. This failed to interrupt her. ' ' 

"I then took her by the hand and led her back 
to the chair in which she had previously been 
sitting. She made no resistance, but sat down 



290 Psychopathology of Hysteria 

quietly and soon became perfectly calm." 

f ' Scratching the back of her hand with a pin, 
pulling her hair, and pinching her face, appeared 
to excite no sensation." 

"I then took off her slippers, and tickled the 
soles of her feet. She at once drew them away, 
but no laughter was produced. As often as this 
experiment was repeated, the feet were drawn 
up. The spinal cord was therefore awake." 

"She had now been downstairs about twenty 
minutes. Desiring to awake her I shook her by 
the shoulders quite violently for several seconds, 
without success. I then took her head between 
my hands and shook it. This proved effectual in 
a little while. She awoke suddenly, looked 
around her for an instant, as if endeavoring to 
comprehend her situation, and then burst into a 
fit of hysterical sobbing. When she recovered 
her equanimity, she had no recollection of any- 
thing that had passed, or of having had a dream 
of any kind." (Sleep and Its Derangements, 
1869, p. 205.) 

The shock of her mother 's death was the prob- 
able cause of this patient's condition. The 
somnambulistic seizures, typical examples of 
Janet's monoideic somnambulism, were evidently 
dependent upon a dissociated complex concern- 
ing her mother. 

During attacks of somnambulism the pa- 
tient's attention is concentrated upon one 
system of ideas to the exclusion of all others. 



Alterations of Consciousness 291 

When we judge a somnambulist 's actions entirely 
as they are adapted to the expression and reali- 
zation of the one system of ideas nothing abnor- 
mal is noticeable. Thus Hammond's patient 
was unable to perceive any stimulus which was 
not related to the death of her mother, and, on 
the other hand, when she was left to herself, the 
character of her actions did not differ mate- 
rially from those of a person in full possession 
of consciousness. 

Any hysteric trance-like state that is asso- 
ciated with monoideic automatism may be con- 
sidered somnambulistic whether it appears dur- 
ing the day or if it develops while the patient 
has been asleep. As a matter of fact even the 
convulsive seizures of hysteria are, as Janet has 
contended, states of monoideic, or, in some cases, 
polyideic somnambulism ; the patient merely liv- 
ing through again some former experience. 
Moreover, convulsive attacks may serve as the 
point of departure for the elaboration of more 
highly developed types of dissociation of con- 
sciousness. 

In addition to psycholeptic seizures Sallie S. 
was subject to occasional somnambulistic attacks. 
During one of these she was taken by her hus- 
band to the office of their physician. While in 
the office she cried, and did not appear to be 
entirely conscious of her surroundings. Indeed, 
she insisted that the physician was unknown to 
her. After returning home and recovering her 



292 Psychopathology of Hysteria 

usual state of consciousness she exhibited amne- 
sia for the whole period of the crisis, and, conse- 
quently, she denied having been out of the house. 
At no time did she believe either her husband or 
her physician when they related what had really 
occurred. While in the hypnotic state she re- 
membered all the events of her crisis. It appears 
that the seizure was consequent upon a state of 
profound meditation concerning the illness and 
death of her first child, and the crying repre- 
sented her grief on this occasion. Her attention 
being concentrated upon these painful memories 
she was oblivious to most extraneous perceptions 
and ideas. 

The lack of recognition of environment ex- 
hibited by somnambulistic patients is similar to 
the normal deficiency of conscious recognition of 
what is perceived but not attended to when one 
has his attention deeply concentrated. 

Ambulatory Automatism and Fugues. The 
more complete the dissociation of consciousness, 
the more closely do the resultant mental states 
and their physical expression resemble normal 
standards. When a person is actuated by one 
idea to the exclusion of all others, his manner 
of reacting to environment is necessarily defec- 
tive. Whereas, the greater the amount of 
cleavage, the better the foundation with which 
to enter into external relations. A necessary 
corollary is that the less the amount of dissocia- 
tion the more numerous must be hallucinations, 



Alterations of Consciousness 293 

and particularly ''negative hallucinations." 
Following the terminology of Janet, let us apply 
the designation polyideic somnambulism to cases 
presenting automatisms dependent upon the 
cleavage of more than one system of memories. 
"With almost imperceptible gradations, cases 
might be adduced beginning with monoideic 
somnambulism and ascending the scale of disso- 
ciation to attain the most highly evolved type 
of the affection — multiple personality. Hand in 
hand with the evolution of dissociation, or the 
development of parasitic and independent per- 
sonalities, is the approach towards the normal 
of the reactions of the individual. Polyideic 
somnambulism, then, is characterized by adapta- 
bility to environment that is far greater than 
that of the monoideic variety. 

The case of Mr. X., which was mentioned in 
the section dealing with asthma, was compli- 
cated by an interesting type of somnambulism 
whose recurrences were discovered to have 
been provoked by association of ideas, and 
whose origin was not as incomprehensible as 
at first one would believe. The case illustrates, 
also, the gradual evolution of a highly devel- 
oped form of polyideic somnambulism — one 
which approached closely veritable multiple 
personality — from what was originally a simple 
type of monoideic somnambulism. In order to 
describe these manifestations allow me to quote 
some selected paragraphs from the original re- 



294 Psychopathology of Hysteria 

port: "Prolonged attacks of coughing, termi- 
nating with the expectoration of glairy mucus 
and the immediate onset of a trance-like state 
that lasted from fifteen minutes to three hours, 
first appeared in 1905. It was noticed that these 
seizures, occurring about ten times annually, 
were always induced by excitement or mental 
stress. Often he walked around during the 
somnambulistic stage, guiding himself by 
tactual perceptions, but he seemed to pay no at- 
tention to what happened, save that he occa- 
sionally answered questions. Though his eyes 
usually remained open and fixed he never ap- 
peared to see anything. He was often observed 
passing his fingers over the crystal of his 
watch; and if the time of one of his engage- 
ments was approaching, as determined by him 
in this manner, he was usually able to bring 
about reversion to the personality normal to 
him.* At the termination of one of these ab- 
normal states of consciousness he would be be- 
wildered for a short time and was never able to 



♦Believing that the watch was .superfluous and that 
his ability to recognize the time was dependent upon 
subconscious registration of the passage of time, Mr. X. 
was tested with a watch which he knew had been set 
incorrectly. He was unable to detect the position of 
the hands when tested in this manner, yet, a few min- 
utes before, he had given out the time within three 
minutes of being correct, even though the watch which 
he had palpated had been concealed from his view, 
there was not any clock in the room, and he had not 
seen a watch, or clock, for at least three quarters of 
an hour. This ability subconsciously to recognize the 
passage of time is the means by which some fortunate 
individuals are able to waken at whatever time they 
desired before going to sleep. 



Alterations of Consciousness 295 

remember what had occurred during their con- 
tinuance. ' ' 

"In addition to the type of seizure just de- 
scribed a variation developed in 1906. Follow- 
ing an emotional shock, worry, or an excessive 
amount of the mental application incidental to 
the pursuit of his profession, a severe paroxysm 
of coughing might appear, succeeded by a 
stuporous condition lasting from one to fifteen 
minutes. After the cessation of this latter 
state he became very loquacious, holding 'tele- 
phonic' conversations in which he talked of his 
business affairs. Though he paid no attention to 
his surroundings he occasionally answered, 
relevantly or not, questions that were addressed 
to him. The fact that he is known to have dis- 
played resistance to passive movements, to- 
gether with other evidences of opposition, would 
tend to indicate the presence of negativism on 
these occasions. During one of these states of 
dissociation he defeated Dr. Kulp at a game of 
chess in which he followed the plays only by 
tactual perceptions. In the course of the two 
years previous to the employment of hypnotic 
methods of treatment, about twelve attacks of 
this type occurred, each of which was followed 
by amnesia localized to the period of disso- 
ciation." 

"Early in the year 1908 Dr. Kulp, in order 
to treat locally an obstinate inflammation of 
the nasopharynx, passed into the patient's 



296 Psychopathology of Hysteria 

posterior nares an applicator on which was 
some cotton saturated with a solution of iodine 
in glycerine. At once there appeared prolonged 
and severe coughing which terminated in a 
somnambulistic condition similar in nature to 
those already described. The possibility of 
this sequence being merely coincidental was 
eliminated by ascertaining that it occurred 
whenever an applicator was passed into the 
posterior nares, even though no solutions were 
employed. After determining this causality 
the applications were of necessity discontinued. ' ' 

"June 4, 1908, the patient, after having lost 
much sleep from coughing during the previous 
night left home at 9.30 a. m. He was after- 
wards informed that when he entered his office 
he acted and talked strangely for a short time 
prior to going into his private room, where he 
was found asleep at 2 p. m. Upon being 
awakened at this time he was in his usual state 
of consciousness and knew nothing of what had 
occurred following his departure from home. 
While out for lunch, and without having had 
any emotional provocation or precursory attack 
of coughing of which he was afterwards con- 
sciously aware, the secondary state again de- 
veloped and continued until his return to the 
office at about 4 p. m. He was never able to 
find out the nature of his actions during this 
second attack of ambulatory automatism." 

"Alarmed by these happenings he went home 



Alterations of Consciousness 297 

and slept until 6 p. m., when he woke up in the 
secondary state. At his lodge, in the evening, 
he talked in a sensible manner to the secretary 
about matters of importance, and then con- 
ferred a degree upon some of the members. 
Later, some of his friends noticed something 
peculiar in his condition and advised him to go 
home. Thereupon he walked home, and his 
wife afterwards reported that upon going to 
bed he had an attack of coughing, followed by 
one of his somnambulistic states of loquacious- 
ness which lasted for two hours. The next 
day, being in his usual state, he was unable to 
remember anything which had happened the 
previous evening except the little he acquired 
through isolated memory flashes." 

"For the purpose of causing a somnambulis- 
tic attack an application was made to his 
posterior nares. There appeared immediately 
a violent paroxysm of uninterrupted coughing, 
similar to that of pertussis, associated with 
clonic movements, almost epileptic in nature, 
of the arms. In the efforts of coughing 
the patient flexed his body extremely and 
appeared to contract every voluntary muscle. 
After coughing about fifty times he became ex- 
hausted, and the cough ceased. Sitting with 
his head in his hands, his breathing became 
deeper, and Cheyne-Stokes type of respiration 
appeared, followed, a coupJe of minutes after 
the last cough, by the onset of unconsciousness. 



298 Psychopathology of Hysteria 

My attempt at experimentation having as its 
end the determination of the character of his 
state, caused, or was coincidental with the re- 
turn of consciousness. On account of his great 
exhaustion it was deemed inadvisable to cause 
a recurrence of the paroxysm; consequently I 
was unable to demonstrate experimentally the 
auto-hypnotic nature of the final stage." 

" During the same evening he was readily 
hypnotized, for the first time, in about one 
minute. After T had made the suggestion that 
he should 'awaken,' about a half hour later, 
his first question was: 'When are you going to 
begin?' The artificial hypnotic dissociation 
was so complete that he was not aware of hav- 
ing been hypnotized; though, by reason of his 
amnesia for all the suggestions that had been 
made, it was apparent that the hypnotic state 
had actually been produced." 

"While he was in the hypnotic state, during 
his third visit — November 23, 1908 — an effort 
was made to determine the causes, of which he 
was consciously unaware, of his manifestations, 
with the following result: Being frequently 
awakened from a sound sleep by the onset of an 
attack of asthma, he acquired the habit of resort- 
ing to the inhalation of fumes from a burning 
asthma powder, while sitting on the side of the 
bed with his head in his hands. The fumes irri- 
tated his larynx and this, in addition to the usual 
postasthmatic tendency to cough, produced a 



Alterations of Consciousness 299 

severe paroxysm of coughing. The great ex- 
haustion following the paroxysm, together with 
the soothing effects of relief from dyspnoea and 
the natural tendency to fall asleep again after 
having been awakened in the middle of the night, 
caused him to fall asleep while sitting there with 
his head in his hands. The repetition of this 
sequence, almost every night, soon resulted in the 
formation of a number of powerful associations, 
and there appeared gradually a tendency to fall 
asleep during the day, after the use of his asthma 
powders. This experience having occurred 
many times a psychic short cut, like those found 
so often in the study of the mechanism of 
hysteric accidents, became established, and the 
more highly elaborated auto-hypnotic or som- 
nambulistic condition began to appear following 
a severe cough even without the asthma powder 
having been used." 

"The local irritation caused by the appli- 
cation to his posterior nares resembled the irri- 
tation due to inhalation of the fumes of his 
asthma powder; the paroxysm of coughing and 
its consequences was therefore the result of asso- 
ciation of ideas. ' ' 

"The beneficial results of suggestion during 
the hypnotic state become apparent immediately 
following his first treatment. During his second 
visit he asserted that he had slept deeply three 
nights out of five without having been awakened 
by an attack of asthma. In addition to this 



300 Psychopathology of Hysteria 

unusual state of affairs he was able to sleep with 
one pillow less under his head. ' ' 

" While under hypnosis the second time, the 
suggestion was made, among others, that par- 
oxysms of coughing and somnambulistic at- 
tacks would never occur again following appli- 
cations to his posterior nares. After being 
aroused from the hypnotic state he was told that 
an application was to be made. Not being con- 
sciously aware of any of the suggestions that had 
been made, he prepared for the usual conse- 
quences. Much to his surprise there occurred 
nothing but a few coughs. ' ' 

"Since Mr. X. first came under my care — 
November 13, 1908 — he has been hypnotized 
only eight times. At present he sleeps well 
without being awakened by asthmatic attacks, 
and instead of having paroxysms of coughing 
when he arises in the morning, only a few coughs 
occur. In fact he now has no paroxysms what- 
ever, and since his first treatment he has not had 
a single one of any of his various somnambulistic 
attacks. " (Jour, of Abnormal Psychology, Aug. 
— Sept., 1909.) 

Somewhat similar to one of the exciting causes 
of the attacks of Mr. X. was one of those of a 
case briefly mentioned by Gowers; the patient 
all of his life being subject to narcoleptic attacks 
whose exciting causes included the passage of a 
probe into a nasal fistula. 

During highly elaborated somnambulistic 



Alterations of Consciousness 301 

states hysteric patients occasionally run away 
from home. Such flights — designated fugues, 
or ambulatory automatism — are the realization 
of former vague desires. Long continued vol- 
untary suppression of unfulfilled desire leads 
to dissociation of a complex of which it is the 
nucleus. If a massive dissociation should occur 
at any time this complex would tend to as- 
sume activity that had for its end accomplish- 
ment of the old longing; whether this be crav- 
ing for travel for its own sake, or simply desire 
to run away as a pusillanimous means of es- 
cape from relatively great responsibilities and 
difficulties. 

When the ordinary annoyances of home life 
become too overwhelming for the sensitive and 
incompetent hysteric to sustain, the thought of 
escape from these tribulations naturally must 
arise. As the hysteric is impulsive — as he tends 
without critical, conscious reflection to act upon 
ideas as they arise — the thought of evasion acts 
with all the force that autosuggestion is ca- 
pable of exerting in this disease. Finally, as 
the consequence of a relatively severe stress, 
or, in fact, even of a minor one that serves as 
the last straw, a superior kind of somnambulis- 
tic condition develops, and in response to an 
irresistible and unquestioned impulse the flight- 
is accomplished. As judged by ordinary stan- 
dards the fugue of hysteria is irrational in 
that the manifestation is out of all proportion 
to the provocation. 



302 Psychopathology of Hysteria 

Fugues are attended by a distinct alteration 
in the personality of the patient; his habits, 
temperament, likes and dislikes, and even his 
name becoming changed. Just as during hys- 
teric attacks the actions and verbal utterances 
reflect the delusions and hallucinations of the 
patient, so the conduct during fugues is that 
which is natural to the patient, but which for- 
merly had been suppressed in the attempt to 
conform to the restraints of home life and to 
the manners and customs imposed by civiliza- 
tion and environment. 

Though his past life may be forgotten — i. e. 
the memories are incapable of volitional re- 
production during the existence of the new 
personality — yet isolated memories at times 
arise above the level of his new state of con- 
sciousness, and, therefore, his actions are not 
those of one who really has had all the mem- 
ories of his preceding life blotted out. In ad- 
dition to these memory flashes what may be 
called general knowledge usually is common 
to both states. It is by reason of these legacies 
from his former life that he is enabled to con- 
duct himself in a manner that does not seem 
peculiar, or abnormal, to those with whom he 
comes into contact; otherwise, soon he would 
be committed to jail, or a hospital. But, as a 
considerable portion of his memories are sub- 
merged the new state must be distinctly in- 
ferior to the old one. In describing the sec- 



Alterations of Consciousness 303 

ondary state of Ansel Bourne, Professor James 
characterizes it as a "rather shrunken, de- 
jected, and amnesic extract of Mr. Bourne 
himself." 

Inasmuch as the specific memories pertain- 
ing to the patient's usual personality and those 
of his state of consciousness during a fugue are 
mutually incompatible he is not cognizant in 
either state of the personal memories of the 
other. This is readily comprehended when we 
consider that often the patient had been sub- 
duing for many months or years the vague de- 
sire to escape from troubles, for the reason that 
in his usual state a flight would have been 
looked upon as cowardly and despicable, had 
he permitted himself seriously to contemplate 
this procedure. Consequently, when the state 
of massive dissociation develops, and the fugue 
becomes a fact, he knows neither why he is 
running away, nor even that he is doing so. 

Besides those occurring as manifestations of 
hysteria, fugues are believed to result less fre- 
quently from trauma, alcoholic and other toxic 
states, degeneracy, and epilepsy. In most of 
the cases which follow trauma the injury acts 
only as an exciting cause, and the fugue itself 
is hysteric in character just as the post- 
traumatic paralysis that is encountered so fre- 
quently in hysteria is usually a psychic paraly- 
sis, and not one which is a direct consequence 
of actual injury to the part. The fugues of 



304 Psychopathology of Hysteria 

degeneracy differ from those of hysteria in that 
the flight is not accompanied by an altered state 
of consciousness, and like the psychasthenic 
fugue, for several days or more before leaving 
home the patient may feel the growth of the 
impulsion to run away, and, accordingly, 
preparations even may be made for the "get 
away." The fugue of either of these conditions 
is voluntary or semi-voluntary, while that of 
hysteria, on the other hand, occurs suddenly 
without any conscious preparations, is effected 
during a deviation from the usual state of con- 
sciousness of the patient, and is followed by 
amnesia for the whole period of its existence. 

As the record of an actual case is far more 
valuable than pages of generalizations allow 
me to quote William James' well known Ansel 
Bourne case of ambulatory automatism and 
then one of my own cases illustrating the fugue 
of degeneracy: 

"The Rev. Ansel Bourne, of Greene, R. L, 
was brought up to the trade of a carpenter; 
but, in consequence of a sudden temporary loss 
of sight and hearing under very peculiar cir- 
cumstances, he became converted from Atheism 
to Christianity just before his thirtieth year, 
and has since that time for the most part lived 
the life of an itinerant preacher. He has been 
subject to headaches and temporary fits of de- 
pression of spirits during most of his life, and 
has had a few fits of unconsciousness lasting 



Alterations of Consciousness 305 

an hour or less. He also has a region of 
somewhat diminished cutaneous sensibility on 
the left thigh. Otherwise his health is good, 
and his muscular strength and endurance ex- 
cellent. He is of a firm and self-reliant disposi- 
tion, a man whose yea is yea and his nay, nay; 
and his character for uprightness is such in the 
community that no person who knows him will 
for a moment admit the possibility of his case 
not being genuine." 

"On January 17, 1887, he drew 551 dollars 
from a bank in Providence with which to pay 
for a certain lot of land in Greene, paid certain 
bills, and got into a Pawtucket horse car. This 
is the last incident which he remembers. He 
did not return home that day and nothing was 
heard of him for two months. He was pub- 
lished in the papers as missing, and foul play 
being suspected, the police sought in vain his 
whereabouts. On the morning of March 14. 
however, at Norristown, Pennsylvania, a man 
calling himself A. J. Brown, who had rented a 
small shop six weeks previously, stocked it with 
stationery, confectionery, fruit and small articles, 
and carried on his quiet trade without seeming to 
any one unnatural or eccentric, woke up in a 
fright and called in the people of the house to 
tell him where he was. He said that his name was 
Ansel Bourne, that he was entirely ignorant of 
Norristown, that he knew nothing of shop-keep- 
ing, and that the last thing he remembered — it 



306 Psychopathology of Hysteria 

seemed only yesterday — was drawing the money 
from the hank, etc., in Providence. He would 
not believe that two months had elapsed. The 
people of the house thought him insane ; and so, 
at first, did Dr. Louis H. Read, whom they called 
in to see him. But on telegraphing to Prov- 
idence, confirmatory messages came, and pres- 
ently his nephew, Mr. Andrew Harris, arrived 
upon the scene, made everything straight, and 
took him home. He was very weak, having 
lost apparently over twenty pounds of flesh 
during his escapade, and had such a horror of 
the idea of the candy-store that he refused to 
set foot in it again." 

"The first two weeks of the period remained 
unaccounted for, as he had no memory, after 
he had once resumed his normal personality, of 
any part of the time, and no one who knew him 
seems to have seen him after he left home. The 
remarkable part of the change is, of course, the 
peculiar occupation which the so-called Brown 
indulged in. Mr. Bourne had never in his life 
had the slightest contact with trade. 'Brown' 
was described by the neighbors as taciturn, 
orderly in his habits, and in no way queer. He 
went to Philadelphia several times ; replenished 
his stock ; cooked for himself in the back shop, 
where he also slept; went regularly to church; 
and once at a prayer-meeting made what was 
considered by the hearers a good address, in 
the course of which he related an incident 



Alterations of Consciousness 307 

which he had witnessed in his natural state of 
Bourne." 

"This was all that was known of the case up 
to June 1890, when I induced Mr. Bourne to 
submit to hypnotism, so as to see whether, 
in the hypnotic trance, his 'Brown' memory 
would not come back. It did so with surpris- 
ing readiness: so much so indeed that it proved 
quite impossible to make him whilst in the hyp- 
nosis remember any of the facts of his normal 
life. He had heard of Ansel Bourne, but 
* didn't know as he had ever met the man.' 
When confronted with Mrs. Bourne he said that 
he had 'never seen the woman before,' etc. On 
the other hand, he told of his peregrinations 
during the lost fortnight, and gave all sorts of 
details about the Norristown episode. The whole 
thing was prosaic enough; and the Brown-per- 
sonality seems to be nothing but a rather 
shrunken, dejected, and amnesic extract of 
Mr. Bourne himself. He gave no motive for 
the wandering except that there was 'trouble 
back there' and he 'wanted rest.' During the 
trance he looks old, the corners of his mouth 
are drawn down, his voice is slow and weak, 
and he sits screening his eyes and trying vainly 
to remember what lay before and after the two 
months of the Brown experience. 'I'm all 
hedged in,' he says: 'I can't get out at either 
end. I don't know what set me down in that 
Pawtucket horse-car, and I don't know how T 



308 Psychopathology of Hysteria 

ever left that store, or what became of it.' His 
eyes are practically normal, and all his sensi- 
bilities (save for tardier response) about the 
same in hypnosis as in waking. I had hoped 
by suggestion, etc., to run the two person- 
alities into one, and make the memories con- 
tinuous, but no artifice would avail to accom- 
plish this, and Mr. Bourne's skull to-day still 
covers two distinct personal selves." (The 
Principles of Psychology, vol. 1, p. 391, 1905.) 

A psychasthenic boy of 17 years had had 
about twenty fugues. The first of these oc- 
curred in his eleventh year and followed a 
quarrel with his aunt, who accused him of steal- 
ing some money from her. The flight, he stated, 
was accomplished of his own free will. He re 
mained away about one week before being dis- 
covered by the police and sent home. During 
the week he had walked the streets looking for 
work, and at night he slept in wagons and 
stables. The second flight took place one week 
after his return from the first one. Having run 
away eight times in the space of one year he 
was sent to a state institution where he re- 
mained nineteen months. Later he was con- 
fined eight months in the same institution. Of 
the large number of his fugues he was brought 
back by the police in all but two, whose ter- 
mination was effected by a sudden and ap- 
parently causeless desire to return home. The 
only time that he stole was to obtain money 



Alterations of Consciousness 309 

for a flight, and his thefts were limited to mem- 
bers of his family. Several days before each 
fugue he became irritable and moody. The 
first one was entirely voluntary, he stated, while 
the others resulted from impulses which he 
could not resist, though he did not exert him- 
self much to do so. Through the agency of 
hypnotic suggestion all of his many psychasthe- 
nic symptoms disappeared, but, after the fourth 
treatment, he failed to return, and several 
weeks later he had a fugue which continued for 
five weeks. 

The last fugue before coming under my care 
illustrates the voluntary, or semi-voluntary, 
nature of those due to degeneracy. Several days 
before the evasion he accidentally discovered 
some money belonging to his father. On aris- 
ing several mornings later he was conscious of 
an impulsion, which he tried to suppress, to 
run away. Just before going to work he ap- 
propriated the money which he had found and 
then boarded a trolley that went past the shop 
where he was employed. While in the car 
something said to him, as he expressed it, "Now 
is your chance." Acting on this impulse he re- 
mained in the car and went to a city thirty 
miles distant. About a week later he felt that 
he was not acting right so he returned home. 

Formerly, all fugues were supposed to be 
manifestations of epilepsy, and, as such, they 
were designated psychic epilepsy. Gradually 



310 Psychopathology of Hysteria 

the tendency has been evolved to ascribe to 
epilepsy but few of the cases, and some au- 
thorities deny that the different phenomena 
which are included under this term have any 
other relation to epilepsy than through their 
superficial resemblance to certain features of 
this disease. Among others who have enlisted 
modern psychoanalytic methods in their in- 
vestigations of psychic epilepsy, Sidis denies 
that epilepsy has any influence in the causation 
of these alterations of consciousness. He 
classifies as recurrent psychomotor states of dis- 
sociation all of the cases known as psychic 
epilepsy, or those exhibiting "psychic equiv- 
alents" of an epileptic attack. Rigid analysis 
of such cases, he states, shows that they have 
nothing to do with epilepsy even though they 
may be found in association with this disease. 
(Boston Med. and Surg. Jour., Mar. 14, 1907.) 

As hysteria and epilepsy often coexist ver- 
itable fugues may occur in patients who are 
subject to indubitable epileptic convulsions 
without, however, signifying that both manifes- 
tations are epileptic in origin. 

Like the fact that on the basis of the seizure 
itself it is impossible to differentiate many cases 
of hysteric psycholepsy from epileptic convul- 
sions, it has been shown by J. W. Courtney that 
the supposed differential signs between the 
fugues of hysteria and those of epilepsy are 
fallacious. He concluded that an epileptic 



Alterations of Consciousness 311 

fugue per se does not possess any peculiarities 
which distinguish it from many of the nights 
of hysteria, and for this reason the diagnosis 
between the two conditions should not be at- 
tempted on the characteristics of the fugue 
alone. (Jour, of Abnormal Psych., vol. 1, p. 
123.) In an exhaustive paper on ambulatory 
automatism Patrick writes: "I do not wish to 
be understood as doubting the existence of 
epileptic wandering. Unequivocal cases are 
sufficiently numerous in the literature. But I 
do insist that this diagnosis has been made too 
often." (Jour, of Nerv. and Ment. Dis., June. 
1907.) 



CHAPTER IX 

Multiple Personality and Amnesia 

WELL developed cases of multiple 
personality are exceedingly rare. 
There are less than fifty recorded 
cases that possess any value, and 
of these only several have been carefully studied 
in the light of our beginning comprehension of 
this phenomenon. In view, then, of the rarity 
of the affection, and of the fact that there is 
much excellent literature devoted to the sub- 
ject, it seems inadvisable in this work to at- 
tempt more than to summarize several of the 
more interesting cases and briefly to describe 
the condition. 

The dividing line between ambulatory auto- 
matism and multiple personality is purely arbi- 
trary; a fugue being merely a lower grade of 
dissociation that eventuates in a flight. On the 
other hand, many of the cases of multiple per- 
sonality exhibited states of consciousness far 
inferior, for instance, to that of the secondary 
state of Ansel Bourne. One might well hesi- 
tate before deciding whether the following 
case, reported by Edward E. Mayer, should be 
classified as a prolonged fugue or as an instance 
of dual personality. The fact that two brief 
fugues interrupted the course of the secondary 
state, and that two occurred subsequently, is 

312 



Multiple Personality and Amnesia 313 

somewhat in favor of designating the case as 
one of fugues. When twenty-four years of age 
the patient had been in a railroad wreck. 
Seventeen years later, while he was suffering 
acute pain, a daughter accidentally overturned 
a lamp. As he tried to catch it he murmured : 
"Oh! my head" and fell unconscious. Upon 
recovering consciousness, twenty-four hours 
later, his first question was whether he was 
much hurt. Then he asked his wife what 
hospital he was in, and if she was the nurse. 
With difficulty he was convinced that he was 
married, the father of four children, and that 
seventeen years had passed since the train 
wreck. Upon inquiry it was evident, too, that 
in his secondary state he had possessed little 
knowledge of his life previous to the accident. 
Having reverted to the primary state he began 
to worry over the possibility of being declared 
insane. Sixteen days after the reversion he had 
a fugue which carried him thirty miles away 
from home during nine hours. The following 
day he disappeared again and nothing further 
was heard from him. (Jour, of the A. M. A., 
1901-2—1601.) 

Multiple personality consists in the alter- 
nation of two or more distinct personalities the 
sum of whose distinctive characteristics roughly 
speaking is equivalent to what should be the 
normal personality of the individual. For in- 
stance, the primary personality of Mayer's case 



314 Psychopathology of Hysteria 

cannot be regarded normal for the reason that 
the memories of seventeen years were lacking. 
Dissociation of the personality implies a div- 
ision of the personality, and. consequently, the 
faculties of one state often are at the ex- 
pense of another. In other words, they are 
complementary. For this reason a hysteric is 
never cured, no matter what may have been 
her symptoms of the disease, unless all of her 
pathologically dissociated memories have been 
restored to consciousness. 

Multiple personality may be consequent upon 
synthesis, independently of consciousness, of 
gradually developing systems of dissociation of 
lesser degree, or it may appear suddenly after 
some severe shock or prolonged mental stress. 
Often there occurs a gradually increasing 
amount of dissociation that manifests itself 
only as a slowly progressive hysteria, or neuras- 
thenia, when suddenly the patient reverts to an 
older state of personality with the consequence 
that she has had blotted out the memories of a 
considerable portion of her life. It is during 
the growth of the secondary personality that 
the patient is most apt to consult a physician, 
and she is treated for neurasthenia or hysteria. 
Then, when reversion occurs, the mistake is 
naturally made to regard as abnormal what 
really approximates more closely the normal 
personality; the reason for this being that in 
the more abnormal state the patient's memory 



Multiple Personality and Amnesia 315 

included the events of her whole life, but, while 
in the primary state, memory is deficient for 
the neurasthenic or hysteric period. 

In several of the early instances a patient 
with symptoms of hysteria, but in whom the 
existence of multiple personality was not sus- 
pected, was hypnotized for the purpose of at- 
tempting to remove symptoms. Finding that 
the supposed hypnotic state was always coinci- 
dent with disappearance of the symptoms, and 
that while in this condition the patient ap- 
peared to be normal and well, what was be- 
lieved to be a hypnotic state was allowed to 
persist when, in reality, it was the normal per- 
sonality, except for loss of memories of the 
secondary state. The case of Marcelline is in- 
structive and it illustrates the above misinter- 
pretation : 

Almost in a dying condition as a result of 
long continued hysteric anorexia and vomiting 
Marcelline was brought to the hospital. More- 
over, she had urinary retention, her skin and 
mucus membranes were completely anaesthetic, 
vision and hearing were much impaired, and 
intellectually she was deficient. Forced feed- 
ing being productive of vomiting, and her con- 
dition being serious, Jules Janet decided to re- 
sort to hypnotism. Having hypnotized her and 
thus afforded her an opportunity to eat without 
subsequent vomiting it was found that all of 
her symptoms had disappeared. The supposed 



316 Psychopathology of Hysteria 

hypnotic state was dispelled because it was 
thought that being an artificial state this was 
necessary. Immediately all of her former 
symptoms returned, and, in addition, she was 
amnesic for the more nearly normal state which 
had been procured. After this the new person- 
ality was frequently induced in order to 
nourish her. This state, however, continued to 
be regarded as hypnotic, and what really was 
a secondary personality with many symptoms 
of major hysteria was believed to be normal. 
Later, the "hypnotic" personality was allowed 
to persist for days at a time in order to avoid 
the necessity of going through the processes of 
hypnotizing her for each meal. One day she 
was taken home by her parents who had found 
her in the artificially induced state and, conse- 
quently, had thought that she had been cured. 

Succeeding her removal from the hospital the 
old state with its hysteric symptoms returned 
every few weeks, so that she was brought back 
to the hospital, solely to be hypnotized, many 
times during the following fifteen years before 
her death from tuberculosis. As each time she 
reverted to the hysteric personality her memory 
was deficient for all the preceding states of the 
primary personality, by the end of five years 
she was ignorant, when in the hysteric state, 
of almost all of her existence since her removal 
from the hospital. At the end of the fifth year 
the experiment was tried of allowing her to re- 



Multiple Personality and Amnesia 317 

main in the secondary state several days in 
order to ascertain if this deficit was more ap- 
parent than real. Because of the many serious 
blunders that she made in consequence of her 
ignorance of her actions and life during these 
five years it was necessary to resort again to 
hypnotic procedures. (Mental State of Hys- 
tericals, p. 433.) In this case, then, the patient 
first came under observation during the exis- 
tence of a secondary personality which was be- 
lieved to be the normal one. By means of sug- 
gestion what approximated the normal person- 
ality was secured instead of what should have 
been the hypnotic state, for which it was mis- 
taken. 

Usually certain knowledge is common to all 
the personalities of a patient. Thus a man who 
in the secondary state is unable to remember 
his name, or any of the incidents of his past 
life, almost invariably possesses his former 
command of language, and his general know- 
ledge remains unimpaired. Figuratively speak- 
ing, it is as if the line of cleavage deprived the 
new state only of that specific knowledge per- 
taining to the former ego; the new personality 
being the product of new experiences and of 
the suppressed tendencies of the original per- 
sonality. In several instances, however, the 
birth of the secondary personality revealed a 
mental state comparable with that of a new 
born infant. In such cases the secondary per- 



318 Psychopathology of Hysteria 

sonality was devoid of all the knowledge that 
had been acquired by the primary one, and the 
alternating personalities had nothing in com- 
mon. The best example of such a type of dis- 
sociation is afforded by the Hanna case: 

While alighting from his carriage the Rev. 
Thomas Carson Hanna made a misstep and fell, 
striking his head. Upon recovering conscious- 
ness, two hours later, his mind was a blank. 
Not only had he lost the faculty of speech, but 
even the ability to recognize objects and per- 
sons. He was unable to appreciate distance, 
form, size, time, etc., and he did not even know 
how to use his muscles. Though the feeling of 
hunger was not affected yet he could not in- 
terpret the craving, and he was ignorant both 
of the purpose of food and of the acts of masti- 
cation and deglutition. Spatial conceptions 
having been lost he attempted to grasp a tree 
seen through a window. Among other curious 
mistakes he thought a man on a bicycle con- 
stituted one living being, while a second man 
and the horse and carriage that he was driving 
were another living being of a different kind. 
In spite of his total amnesia he was very intelli- 
gent. At the end of one week of instruction he 
was able to read, and six weeks after the acci- 
dent he could talk intelligently. His dreams, 
derived from experiences of the normal person- 
ality, were so vivid that it seemed as if he lived 
over again past occurrences without, however, 



Multiple Personality and Amnesia 319 

recognizing them as such. With hypnoidi- 
zation the same kind of hallucinations from the 
past could be obtained. Conservation of the 
memories of the primary personality was shown 
also by his ability to solve geometrical prob- 
lems without being able to explain how he did 
so. 

It was thought that a large number of stimuli 
whose nature differed from that to which the 
new personality was accustomed might raise 
above the threshold of consciousness the sub- 
merged memories of his past life. If success- 
ful, such a procedure would represent fusion of 
the two personalities. Accordingly, he was 
taken to New York and subjected to a lively 
round of amusements. Two hours after having 
retired he woke as the normal Mr. Hanna, who 
was much surprised to find himself among 
strangers, and in strange quarters. He thought 
that he had been the victim of some practical 
joke. During the following six days the two 
personalities alternated until finally, during a 
psychic crisis, fusion occurred — the two states 
became synthetized. (Sidis and Goodhart : 
Multiple Personality, 1905.) 

With this patient the two personalities had 
been entirely ignorant of one another. Not 
any knowledge was held in common. Each 
alternation was preceded by a stuporous state 
that was termed hypnoleptic. Apropos to this 
state Sidis formulated the following law: "no 



320 Psychopathology of Hysteria 

mental alternation without some form of an in- 
termediate sleeping state in general and of a 
hypnoleptic state in particular, especially in the 
transition from the primary to the secondary 
moment.' f "The hypnoleptic state," he con- 
tinues, "is the reproduction of the original at- 
tack which brought about the state of double or 
multiple consciousness .;" It would seem, how- 
ever, that such a twilight state objectively is not 
always appreciable in all cases, though no doubt 
it exists subjectively. In the Beauchamp case, 
for instance, Prince often failed at the time to 
detect an alternation that took place in his 
presence. 

The Hanna case can be regarded as an instance 
of a cure of dissolution of personality for the 
reason that, after having recovered, Mr. Hanna 
possessed the memories of both states. That 
the synthesis of the two personalities was not 
merely temporary is shown by Mr. Hanna 's 
statement, twelve years after the accident, that 
he had remained well. (Ladies' Home Journal, 
Nov., 1909.) 

Somewhat resembling the Hanna case is that 
of Mary Reynolds, recorded by S. Weir 
Mitchell. (Trans, of the Coll. of Physic, of 
Phila., April 4, 1888.) Mary Reynolds had 
been subject to various manifestations of hys- 
teria, when, one day, she woke from a pro- 
longed sleep in a state of complete amnesia for 
her former life. Like Mr. Hanna, when his 



Multiple Personality and Amnesia 321 

secondary personality had just appeared, she 
was as a new born babe, and did not even 
recognize her parents. She, too, learned to 
read and write in a few weeks. Formerly Miss 
Reynolds had been reserved, and melancholic, 
but the alternation of personality was accom- 
panied by an alteration of disposition, and 
she became cheerful, merry and social. The 
secondary state having continued five weeks 
she woke, one morning, in her primary state 
greatly surprised to find so many changes had 
occurred in her environment in the course of 
what she supposed to be one night. She was 
entirely unconscious of the previous five weeks. 
After a few more weeks she woke again in the 
secondary state to take up her life and memo- 
ries just where they had been interrupted by 
the appearance of the primary state. The al- 
ternations continued to take place for fifteen 
or sixteen years, but they finally ceased, leav- 
ing her permanently in the secondary state at 
the age of thirty-five or thirty-six. 

As lapses of memory play such an important 
part in the progress of a case of dissociated 
personality it might be thought that the syn- 
drome is merely a manifestation of systems of 
localized amnesias. This, however, does not 
appear to be the case, for while embarrass- 
ments of memory are responsible for many of 
the phenomena of the condition, alternating 
periods of amnesia cannot of themselves pro- 



322 Psychopathology of Hysteria 

duce true variations in the personality of the 
patient — the variations of tastes, tempera- 
ment, moral characteristics, and of all the other 
factors which enter into the make-up of what 
is called personality. As a matter of fact 
amnesia is not even a necessary accompani- 
ment of dissociation of the personality just as 
succeeding amnesia is not essential to the hyp- 
notic state. 

The psychic nature of manifestations of 
hysteria is made strikingly apparent in many 
of the instances of multiple personality. For 
instance, Louis Vive, whose moral character 
had been none too good, and who had been 
committed for theft, was bitten by a viper with 
the consequence that he had a convulsion fol- 
lowed by the appearance of a new personality 
which lasted three years. During the existence 
of this secondary personality the memory of his 
previous life was not greatly impaired, his 
moral character changed decidedly for the 
better, and he was paraplegic, and subject to 
hysteric convulsions. At the expiration of the 
third year a prolonged convulsive seizure 
ushered in a new personality, and immediately 
the paraplegia disappeared, to be replaced by 
hemiplegia and hemianesthesia. In this third 
state he was amnesic for the whole of the 
second one, and morally he had so deteriorated 
that he drank, stole, and was quarrelsome. The 
case was further complicated by the develop- 



Multiple Personality and Amnesia 323 

ment of other personalities with corresponding 
variations of the memory, morals, and physical 
manifestations. 

Beginning with morbid somnolence and end- 
ing with multiple personality all the different 
kinds of alterations of consciousness that occur 
as manifestations of hysteria can be reproduced 
also by means of suggestion. That the phe- 
nomena of hyposis are due to an artificially 
induced dissociation of consciousness has been 
quite generally accepted as the most plausible 
explanation. In certain individuals it is possi- 
ble to obtain so highly a developed state of 
what is called hypnotic somnambulism that to 
the uninitiated observer the state of the subject 
apparently differs in no way from what might 
be regarded normal. While in this secondary 
state what constitutes the personality of the 
subject spontaneously may have become 
changed, or quite readily such alterations may 
be brought about through the agency of sug- 
gestion. In either case the condition is a true 
secondary personality of hypnotic origin. 
With certain of these cases the new personality 
could be caused to persist indefinitely. Thus, 
a French physician, with all the enthusiasm of 
the early mesmerizers, allowed the hypnotic 
personalities of two sisters to continue for three 
months. Upon being caused to revert to their 
usual personalities neither of these girls could 
remember anything which had occurred during 
the existence of the secondary states. 



324 Psychopathology of Hysteria 

A well developed case of multiple personality 
originating from the abuse of hypnotism is that 
of Pierre Janet's patient Madame B. This pa- 
tient had possessed a good foundation for the 
development of multiple personality in that she 
had been subject to attacks of nocturnal som- 
nambulism since her third year. After having 
attained the age of sixteen years she had con- 
stantly been used by laymen and physicians as 
a subject for hypnosis. The hypnotic state had 
been induced so frequently, and while in this 
state she had been subjected to so much experi- 
mentation and clinical education, that a well 
organized hypnotic personality — Leontine — 
had become elaborated; one which differed 
completely from Leonie, the " normal' ' 
Madame B. Leonie, a poor peasant, was a seri- 
ous, timid, melancholy woman, while Leontine 
was gay, noisy, restless, and ironical. The 
memory of Leonie was impaired — she was 
amnesic for all the periods when Madame B. 's 
other personalities were uppermost. Though 
Leontine 's memory included that of Leonie, she 
separated the two states and looked upon as 
her own only the memories of events which oc- 
curred when her own personality controlled the 
body of Madame B. Thus Leontine considered 
her husband as belonging to "that good wo- 
man" "the other" who "is not I, she is too 
stupid"; but the children she called her own 
because they were born while Madame B. was 



Multiple Personality and Amnesia 325 

in a hypnotic state ; induced for the purpose of 
rendering the event painless. When Leontine 
was subjected to further hypnotic procedures 
there appeared a third personality, known as 
Leonore, who did not wish to be mistaken for 
that "good, but stupid, woman" Leonie nor 
for the "foolish babbler" Leontine. The 
Leonore personality seemed superior to either 
of the others both in respect to character and to 
memory, which included the whole of Madame 
B.'s life. (Revue Philosophique, Mar. 1888. 
The above account is based upon the abstracts 
of Prof. James and of F. W. H. Myers.) 

The most interesting of the cases of psychic 
polyzoism is the complex Beauchamp case which 
was studied so exhaustively by Morton Prince. 
It is the careful analysis of this, and of other 
similar cases, that has been productive of much 
valuable information concerning functional am- 
nesia, pathogenic submerged memory com- 
plexes, association of ideas, the subconscious, and 
many other of the problems of morbid psychol- 
ogy. (The Dissociation of a Personality, 1906.) 

In her early life Miss Beauchamp had been de- 
cidedly neurotic. One day, in 1893, she was sub- 
jected to a number of stresses culminating in an 
unpleasant experience whose importance was great- 
ly exaggerated by her, and which resulted in the 
birth of a new personality — B. I. Like Leontine, 
and the secondary personalities of Louis Vive, 
and of Marcelline, B. I did not present any gross 



326 Psychopathology of Hysteria 

impairment of the memories of her previous 
life. Being the subject of a decided neuras- 
thenic-like state she came under the care of 
Dr. Prince in 1898. Resorting to hypnosis, 
Prince secured a somnambulistic state which 
was superior to the B. I personality and which 
he utilized as a means of obtaining the bene- 
ficial effects of suggestion. Soon, however, a 
new personality — Sally — sprung out of the hyp- 
notic state without having been produced arti- 
ficially by suggestion. This new personality 
apparently had been a co-conscious one the 
whole of Miss B.'s life, and it continued to 
be co-conscious even during sleep, delirium, 
etherization, and whenever the B. I state was 
in the ascendancy. But, following its emancipa- 
tion during hypnosis, it became, also, a true 
alternating personality. Sally was superior to 
B. I in that she was not amnesic, and she was 
co-conscious with the latter. B. I however, 
was ignorant of all that concerned Sally. 

A year after Sally appeared upon the scene, B. 
I had been caused, by chance association of ideas, 
to recall the primary pathogenic experience 
with the consequence that still another person- 
ality developed. This one, B. IV remembered 
her former life up until the dissolution of 
personality — she knew nothing of B. I, nor of 
Sally, and they, in turn, were ignorant of her 
memories. 

Let us examine, now, the differences in the 



Multiple Personality and Amnesia 327 

personalities. In addition to being subject to 
spontaneous somnambulism, B. I was extremely 
neurasthenic, aboulic, morbidly reticent, sensi- 
tive and emotional. Among other good quali- 
ties, she was modest, conscientious, truthful, 
refined, well educated, and a bibliophile. Hav- 
ing studied stenography and the French lan- 
guage after the disintegration of personality 
had occurred this knowledge, in common with 
other knowledge pertaining to the B. I state, 
was not shared with Sally and B. IV. 

Like those of B. IV, the qualities of the Sally 
personality were complementary to B. I. De- 
spising B. I on account of her popularity, su- 
perior attainments, and poor health, Sally 
was mischievous, childish, impolite, rebellious 
and fond of slang. In addition to her occur- 
rence as an independent personality, and as a 
co-conscious state with B. I, Sally was partially 
(co-conscious with B. IV in that she was aware 
of the actions and the words, but not of the 
thoughts of B. IV. By means of obsessions she 
could control the actions, and even the percep- 
tions, of B. I and B. IV. Subjectively, her 
health was excellent, though she was totally 
anaesthetic and without the senses of hunger, 
thirst, fatigue, and of time. 

The personality of B. IV was superior either 
to Sally or to B. I. Though neurasthenic, her 
health was fair. She was ambitious, selfish, 
affable, and had no compunction about lying 



328 Psychopathology of Hysteria 

whenever necessary. The only knowledge she 
had of B. I was obtained : 1, from isolated mem- 
ory flashes; 2, by means of crystal vision; 3, 
through the agency of self-induced states of 
abstraction she could evoke visual and auditory 
hallucinations concerning B. I. She could not 
revive any of the memories of the Sally state. 

Until the normal personality was obtained, 
in 1902, by suggesting to the hypnotic personal- 
ity that it should "wake" from hypnosis with- 
out becoming disassociated either into B. I or 
into B. IV, all of the personalities continually 
alternated. Often the alternations occurred 
many times in the course of a day. At other 
times one personality might remain in the 
ascendancy for weeks at a time. After the 
normal Miss B. had been obtained all of the 
personalities alternated infrequently until, in 
1905, the synthesis became permanent. It is 
interesting to note that early in the case Prince 
believed that if the hypnotic personality could 
be wakened without losing its identity the 
normal Miss B. would be secured. On attempt- 
ing to do so, however, he had produced what 
resembled a state of dementia. The explana- 
tion afterwards came from the mischievous 
Sally, who, not wishing to sacrifice her 
independence, had been able, as a co-conscious 
personality, to bring about this dementia-like 
state. 

The normal Miss B. represented union of the 



Multiple Personality and Amnesia 329 

B. I and B. IV personalities; Sally, the co- 
conscious personality, being necessarily included 
in the synthesis. In this case the production of 
a normal personality by means of hypnosis il- 
lustrates how the supposed abnormal hypnotic 
states were really the normal personalities of 
Marcelline and of other reported cases. 

The following notes include some of the 
unique and interesting features of the Beau- 
champ case : The personalities Sally and B. IV 
did their best to prevent synthesis because each 
desired to maintain an independent existence. 
In fact, Sally disrespectfully upbraided Dr. 
Prince on one occasion solely because the suc- 
cess of his efforts to cure Miss B. would neces- 
sitate the conclusion of her own independent 
existence. In their attempts exclusively to 
reign over the body of Miss B. both Sally and 
B. IV carried on a bitter and spirited warfare 
in which, at times, they seemed to forget 
that when the body of Miss B. became the 
instrument of their hostilities each of the 
personalities also would suffer. To illustrate 
the extremes to which the struggle was carried, 
once Sally took four calomel pills and then 
resigned the body of Miss B. to B. IV. Another 
time she smoked a number of cigarettes in 
order to make B. IV ill. On still another occa- 
sion she had partaken of wine, and then, prob- 
ably by accident, instead of changing to B. IV, 
the inoffensive B. I, who was unaccustomed to 



330 Psychopathology of Hysteria 

wine, arrived on the scene to find herself some- 
what intoxicated. Indeed, B. I became so 
harassed by the protracted contest that once 
she tried to commit suicide with illuminating 
gas, but Sally came to the rescue by turning 
off the gas and opening the windows. 

The differences in the character of the per- 
sonalities was most decided. Thus B. I could 
not take a single glass of wine without feel- 
ing uncomfortable, while B. IV had taken, 
without any such effects, as many as three or 
four glasses of champagne, followed by three 
or four cocktails and several glasses of liqueur. 
The odor of cigarettes was offensive to B. I and 
she had moral objections to smoking, but B. 
IV was very fond of cigarettes, of which she 
smoked a large number without feeling any ill 
effects. In fact, the tastes and the religious 
and other moral characteristics of B. IV were 
almost the opposite of those of B. I. 

In instances like the Hanna case, in which 
the personality presumably had been entirely 
normal until some violent shock effected imme- 
diate dissociation with the production of a 
secondary state that was infantile in type, it 
seems that but two states exist for the reason 
that the i secondary one is largely the product 
of new experiences and thus is not formed at 
the expense of the normal one.) When a nor- 
mal person develops obvious manifestations of 



Multiple Personality and Amnesia 331 

hysteria dissociation of his personality already 
has occurred and, in reality, there exist two 
secondary personalities ; one being apparent 
and the other latent. The only reason why the 
latent one does not commonly appear as an 
alternating personality is because it is too 
fragmentary to maintain an independent exist- 
ence. Clinically it is possible in the ordinary 
case of hysteria to demonstrate the existence of 
such incomplete personalities. In the cases of 
multiple personality of gradual onset we can 
assume, therefore, that there are always at least 
three personalities : the normal one, the grad- 
ually developed hysteric personality, and its 
complement. The prevention of alternation of 
the personalities of such cases does not consti- 
tute a cure : the secondary personalities must be 
fused before the normal one can be obtained. 
In the Beauchamp case, for instance, if either 
the B. I or B. IV personalities could have been 
prolonged indefinitely without alternation the 
result would not have been a cure for the 
reason that neither of these personalities 
represented the normal Miss B. 

All of us have probably experienced tenden- 
cies to do things which were inconsistent with 
conduct conformable with the obligations im- 
posed by occupation, finances, home life, social 
status, etc. Being incompatible with our ex- 
ternal relations, such thoughts were sup- 
pressed. Simply being submerged, these ideas 



332 Psychopathology of Hysteria 

continue to exert a modifying influence upon 
the better side of the ego, thus producing 
what might be called an (average personality.^ 
In fact, we are all both better and worse than 
we appear to be to others, and our personalities, 
both as viewed by others and by ourselves, are 
merely masks which serve to screen the pos- 
sibilities for good or evil that exist within us. 
Under favorable circumstances one who has 
been a criminal may live as an average in- 
dividual, while if we should transfer the ex- 
ceptional person to an environment where he 
is exposed to various stresses, we might bring 
into evidence traits which neither he nor his 
friends ever suspected. When dissociation 
occurs it is but natural that one personality 
should be lively and not too scrupulous while 
the other exhibits puritanical tendencies. Study 
of most of the reported cases of multiple 
personality shows this difference of moral 
characteristics. 

Amnesia. Organic failure of memory is 
characterized by loss of the recently acquired 
memories, followed by progressive obliteration 
of the older and more stable ones. Ordinarily 
the mechanism of amnesia is divided into 
defects of registration, of conservation, and of 
reproduction. To speak of an amnesia resulting 
from imperfect registration, however, is not 
logical, for what has not been registered cannot 



Multiple Personality and Amnesia 333 

be forgotten — one cannot lose something which 
he never possessed. 

It is well known that functional amnesia is 
never due to absence of conservation — to 
actual loss of memory — but that it is merely 
consequent upon the patient's inability con- 
sciously to reproduce the "forgotten" mem- 
ories. Through the agency of certain well- 
known means proof of this fundamental propo- 
sition is obtainable without difficulty, and it is 
possible to demonstrate that what has been 
forgotten has only been dissociated from con- 
sciousness, and, therefore, has not been lost. 
Instead, then, of being a loss of memory the 
amnesia of hysteria is merely the result of 
elision from consciousness of certain systems 
of memories which subconsciously are con- 
served, or are part of a parasitic personality 
made up by synthesis of other dissociated 
memories and mental states. But, all kinds of 
functional amnesia are not explainable in this 
manner. The memories of events which 
occurred during any of the many kinds of 
seizures or somnambulistic conditions — devi- 
ations from the usual state of consciousness 
— are bound up with the memory complexes of 
that state, so that ordinarily they are incapable 
of conscious reproduction because they had 
never been components of the usual state of 
consciousness of the patient. During recur- 
rences of like somnambulistic conditions these 



334 Psychopathology of Hysteria 

dissociated memories become part of the state 
of the patient's consciousness at the time be- 
cause they pertain to that state and not to the 
usual one. It is the same with what is called 
hypnotic somnambulism. During this artificial 
state the patient is capable of remembering the 
events of all previous states of like nature, yet, 
when aroused from hypnosis, all of these mem- 
ories become dissociated. 

Quite commonly hysterics complain of their 
poor memories and state that they cannot even 
remember what they have been told a minute 
before or what they have had for breakfast. 
Tell a hysteric to do something and usually she 
will not carry out the instructions correctly 
unless they are repeated. Ask her what you 
have told her, and she will answer that she 
doesn't know, or that she has forgotten. All 
of this, however, is not evidence of amnesia. 
The patient did not pay any attention to what 
she was eating, and you could plainly see that 
she was thinking about something else while 
you were talking to her. A man whose atten- 
tion has been concentrated upon his work, and 
who has been thinking deeply, not only is 
unable to tell what hour was struck the minute 
before, but he may be consciously unaware even 
that the hour has been sounded. Neither can 
we call this ordinary incident amnesia, for there 
was absence of conscious perception of the 



Multiple Personality and Amnesia 335 

striking of the clock, and of the same nature 
is much of the so-called amnesia of hysteria. 

The pseudo-amnesia of inattention might 
serve as the foundation from which by auto- 
suggestion, or expectant attention, different 
kinds of functional amnesia might be evolved. 
The symptomatic loss of memory occasioned by 
trauma, and by an alcoholic debauch, or other 
toxic state, also might attract the patient's 
attention to the possibility of this symptom. 
Finally, amnesia is autogenous when it occurs 
as one of the phenomena of some alteration of 
consciousness. 

When physicians specifically interrogate 
hysteric patients about general deterioration of 
memory, or about definitely localized loss of 
memory, they reveal by their direct questions 
that these manifestations are to be expected. 
Consequently, sooner or later the patients very 
accommodatingly begin to exhibit amnesias 
originating from unconscious autosuggestion, 
and which cannot be regarded as differing in 
any manner from those which are deliberately 
produced by suggestion, either during, or in 
the absence of, hypnosis. Except the localized 
amnesias incidental to the attacks of hysteria — 
convulsive, somnambulistic, etc. — one rarely 
encounters independent amnesia in hysterics 
unless they have been subjected to suggestive 
inquiries which tend to bring about the condi- 
tion which is sought. 



336 Psychopathology of Hysteria 

An interesting feature which renders psy- 
choanalysis and treatment more difficult is that 
the amnesias of attacks are inclined to be re- 
trograde inasmuch as the primary and individ- 
ual causes are forgotten. So also the patient 
usually is not consciously aware of the initial 
exciting cause of her disease. Thus, Janet's 
patient Marie, whose case has already been 
mentioned, had completely forgotten about the 
successful and disastrous suppression of her 
first menstrual period, and Sallie S. did not 
remember that her attacks followed references 
to her dead child. The explanation depends 
upon reaction of defense. 

As the exciting cause of hysteria and of its 
manifestations frequently is some experience 
which, being decidedly unpleasant to the 
patient, she endeavored to forget, its memory 
complex became elided from consciousness with 
that facility with which dissociation occurs in 
hysteria. Furthermore, any idea which by 
association causes, or tends to cause, reproduc- 
tion of the painful memories, itself is disposed 
to become a component of the submerged 
complex, which continually increases in mag- 
nitude with corresponding increase in liabil- 
ity to automatisms. "We ask," writes Ernest 
Jones, (Jour, of Abnormal Psych., vol. 4, p. 
224,) "why the patient wished to forget the 
memories in question, and we find it was be- 
cause they are associated with other more pain- 



Multiple Personality and Amnesia 337 

ful thoughts he did not wish to recall. We 
then go on to ask why these other thoughts 
were too painful to recall, and we get a 
precisely similar answer, namely because they 
are associated with yet deeper thoughts which 
he was still more desirous not to recall. "We 
continue the investigation in the same way, 
constantly asking 'Why?' and constantly pen- 
etrating deeper and deeper into the patient's 
mind, and reading further and further back 
into his earliest memories. The pathogenic 
chain of associations is in this way traced to 
its original starting point." 

An instructive case of psychasthenia exhib- 
ited in an unmistakable manner the incom- 
patibility of dissociated memories with con- 
sciousness. Though possessing a nervous tem- 
perament the patient had never really been ill 
or subject to unequivocal nervous manifesta- 
tions until she was confined to bed four months 
as the result of an attack of "nervous prostra- 
tion" which occurred four years before coming 
under my observation. Following the illness 
she became obsessed with indefinite fear which 
compelled her, no matter how much she re- 
sisted, continually to look behind her. This 
phobia attacked her impartially at any time, 
and in any place. When interrogated she 
stated that she believed the apprehension to be 
based upon unreasoning fear of being struck 
from the rear, but she was positive in her as- 



338 Psychopathology of Hysteria 

sertions of ignorance of its cause. Frequently 
she experienced visual hallucinations of a sea 
of blood. 

Attempts to induce hypnosis resulted only 
in a hypnoidal state, during which the patient 
insisted that she was not at all influenced, 
even though unable to open her eyes. During 
her second visit a hypnoidal state again was 
induced, and efforts were made to discover the 
causes of her different manifestations. On this 
occasion it required five minutes of persuasion 
and suggestion before she could be prevailed 
upon to talk. Afterwards she confessed that 
her reluctance was due to a desire to show me 
that she was not hypnotized, and that she did 
not have to do as I said. With the patient in 
this imperfect hypnotic state the following in- 
formation was obtained : 

The attack of "nervous prostration" was 
precipitated by a quarrel during which her 
mother threatened to kill her. (The patient 
herself was a mild-mannered and most inoffen- 
sive woman.) She believed her mother was in- 
sane but was reluctant to express this opinion 
because it was contrary to that of a physician. 
Following her illness the visual hallucination 
of blood appeared, at first only after disputes 
with her mother, but the tendency for their 
recurrence became so developed and so ex- 
panded that soon they occurred after minor 
quarrels with anyone. The irresistible impul- 



Multiple Personality and Amnesia 339 

sion to look behind her appeared about four 
months after the quarrel, and was due, she said, 
to fear of being struck on the head. This 
obsession originally disturbed her only when 
she was at home, and it was a manifestation 
of fear that her mother would carry out her 
threat. Later, the tendency of the psycho- 
neuroses pathologically to exaggerate what pri- 
marily were normal reactions caused this justi- 
fiable fear to become so expanded and so incon- 
gruous that it occurred anywhere, and with- 
out unusual provocation. Being of a painful 
nature the memory complex of the cause of the 
original normal reaction was suppressed from 
consciousness so that ultimately the patient 
became unaware of the origin of the phobia 
and of other manifestations which resulted 
from the quarrel. 

After her usual state of consciousness was 
restored she asserted, as before, that she had 
not been hypnotized, and that she did not wish 
to deceive me by allowing me to think other- 
wise. Although she could recall much of what 
had been said during the hypnoidal state, and 
notwithstanding that she believed that she re- 
membered the entire conversation, it became 
apparent, however, that she was unaware of 
the whole of what she had said in connection 
with the genesis of all of her many symptoms. 
Incidental^, her suicidal tendencies, phobias, 
and other obsessions disappeared completely 



340 Psychopathology of Hysteria 

after their origin was explained to her, and 
after she had received four treatments with 
suggestion and psychic re-education. 

Anterograde, or continuous, amnesia is the 
result of dissociation of memories almost as 
soon as they are formed and to a great degree 
probably depends upon inattention. The most 
celebrated example of this defect, in association 
with retrograde amnesia, is the case of Madame 
D., which was studied by Charcot, Souques and 
Janet. Having been told falsely that her hus- 
band was being brought home dead Madame D. 
had an attack of hysteric convulsions and 
delirium that continued for three days. Fol- 
lowing the crisis not only was she unable to 
remember all that had occurred during the two 
preceding months, but for nine months she 
continued to forget whatever occurred the 
minute before. 

Amnesias are localized when whole periods 
are blotted out, and they occur in this manner 
in almost all patients who are subject to the 
attacks of hysteria. This form of defective re- 
production is most obtrusive in connection 
with the alternations of fugues and of multiple 
personality because the forgotten periods are 
longer than those of other states of disturb- 
ance of consciousness, and because these alter- 
nations do not incapacitate the patient from 
maintaining his external relations. Naturally 
it is important that one should remember what 



Multiple Personality and Amnesia 341 

new acquaintances have been formed, what en- 
gagements have been made, or where money 
has been safely placed away during the preced- 
ing days, or weeks, or months. 

When the patient is unable to remember 
certain systems of knowledge the amnesia is 
systematized. Not only is the following case, 
reported by Breuer and Freud, a beautiful ex- 
ample of systematized amnestic aphasia, but it 
illustrates well the manner in which the de- 
velopment of symptoms may be deferred. One 
night, while somewhat confused and exhausted 
from nursing her father, Fraiilein Anna O. 
experienced a hallucination which frightened 
her. At first she was unable to recall any 
words; then she remembered an English 
prayer. Subsequently, on developing grave 
hysteria whose symptoms were based mainly 
on the incidents of her father's fatal illness, 
she lost entirely, for a period of a year and a 
half, the use and comprehension of the German 
language while retaining her command of 
English. (Selected Papers on Hysteria and 
Other Psychoneuroses, trans, by A. A. Brill, 
1909, p. 2.) 

As already mentioned, the proof that the 
amnesias of hysteria are not dependent upon 
irretrievable loss of memories — faulty conser- 
vation — rests with the successful application 
of measures having as their end the reproduc- 
tion of what has been forgotten. First, how- 



342 Psychopathology of Hysteria 

ever, let us consider several of the ways in 
which spontaneously the patient gives evidence 
that the lost memories are really retained, and 
that the loss consists only in the patient's in- 
ability consciously to recall them. Investiga- 
tion of the dreams of hysterics ordinarily shows 
that they are composed of the very memories 
which have been dissociated. For instance, 
in the Hanna case of dual personality vivid 
dreams occurred which, upon investigation, 
were found to contain elements of what had 
happened prior to dissociation. Such dreams 
included the names of persons, of objects, and 
of places which in his secondary state were 
meaningless to him. 

In the course of the various attacks of hys- 
teria quite as common is the display of knowl- 
edge of incidents which could not be recalled 
during the usual state of consciousness. Not 
only by their actions but also by their verbal 
utterances do these patients show recollection 
of what consciously cannot be remembered. 
Moreover, both the hallucinations which are 
experienced during less obvious alterations of 
consciousness, and the memory flashes which 
occur so frequently in cases of multiple per- 
sonality, indubitably establish the preservation 
of memories which may have been deemed ir- 
recoverable. 

As the loss of memory is always more ap- 
parent than real, and as the trouble depends 



Multiple Personality and Amnesia 343 

solely npon defective reproduction, the physi- 
cian must assume that the patient knows the 
facts which are desired, and to be successful 
he must not permit the patient to gain the idea 
that any doubt is entertained relative to the 
outcome of the investigation, and professions 
of ignorance never should be accepted. Since 
recurrence of seizures is effected by association 
of ideas which produce an upward flow into 
consciousness of dissociated systems with their 
morbid psychomotor expression, efforts to re- 
produce pathogenic complexes may be attended 
with the production of the attacks with which 
they are associated. This, however, is unusual 
and is easily prevented by .suggestion, or the 
attack cut short by the same means. Much 
valuable information can be acquired through 
the induction of a single crisis, but it is de- 
cidedly unwise to encourage the pathologic 
disposition by unnecessary reproduction of 
seizures. 

Inasmuch as functional lapses of memory 
are due to the objectionable nature of what 
has been forgotten, in his efforts to bring about 
reproduction the physician has to contend with 
the forces of the patient which strive to pre- 
vent the submerged memories from becoming 
conscious. The more nearly the patient's state 
of consciousness approaches that which is 
usual the greater the amount of unconscious 
inhibition exerted towards the prevention of 



344 Psychopathology of Hysteria 

reproduction. When through the agency of 
hypnotic procedures we effect an artificial 
dissociation of consciousness inhibition of the 
submerged memories to a great extent is lost, 
and, therefore, the patient is able to relate the 
experiences which she cannot remember while 
in her normal state. In the psychoanalysis of 
those whom we may term good hypnotic subjects 
the hypnotic method is by far the least difficult 
in its application and the most prolific of the 
information which is sought. 

Not every hysteric can be hypnotized so deeply 
as to become somnambulic. The best means of 
obtaining profound hypnosis consists in explain- 
ing beforehand what is about to be done and 
what condition is about to be secured. Pro- 
ceeding, then, to hypnosigenesis, the physician 
attempts by means of further suggestions to 
induce somnambulism. But, if the desired 
state is not obtained — as will occur in from 
10-30% of cases — the physician who has pre- 
dicted, and who is suggesting the appearance 
of, conditions that do not materialize, thereby 
not only subjects himself to embarrassment, but 
he loses, to a certain extent, the patient's con- 
fidence. Consequently, under these circumstan- 
ces reproduction of the submerged memories is 
usually difficult, if not impossible. 

In order to avoid these difficulties Freud 
(Selected Papers on Hysteria, Brill trans.) 
adopted the following technique: Having the 



Multiple Personality and Amnesia 345 

patient lie down with the eyes closed, he re- 
quires her to concentrate her attention on what 
is about to be done. In this manner he obtains 
as profound a state of hypnosis as possible 
without, however, compromising himself by 
making false predictions and unsuccessful sug- 
gestions. While the patient relates her history 
gaps become apparent; she avoids certain 
periods, or leaves out causal events. When 
urged to remember the important memory 
complexes which these gaps represent she often 
protests that she cannot. Accordingly, an 
artifice is adopted which depends upon rein- 
forced suggestion. Placing his hand upon the 
patient's forehead, Freud affirms that under 
the pressure of his hand the desired informa- 
tion will come into her mind, or that she will 
see some picture before her. Soon he found 
that all thoughts secured in this manner were 
relevant, and that a negative response never 
should be accepted, for when the procedure at 
first is unsuccessful the failure does not indi- 
cate that the right thought did not come into 
the patient's mind, but that, being of a 
distressing nature, it was repudiated as irrele- 
vant, or too painful to entertain, just as 
originally the complex was submerged. 

By means of the hypnoidal state Sidis, 
Coriat, White, Donley, Parker, and others have 
been very successful in the psychoanalysis of 
functional neuroses. The hypnoidal state of 



346 Psychopathology of Hysteria 

Sidis consists in an unstable state of abstrac- 
tion that intervenes between the waking state, 
on one hand, and either hypnosis or sleep on 
the other. As the amount of dissociation 
which accompanies the production of this 
state is neither profound nor constant, the 
submerged memories which arise are not com- 
plete, nor are they consecutive. Mainly on 
this account the results obtained with this 
method of reproduction of forgotten memories 
in my experience have not been as satisfactory 
as those secured with hypnosis. As described 
by Sidis, the mode of induction of the hypnoidal 
state is as follows: 

"The patient is asked to close his eyes and 
keep as quiet as possible, without, however, 
making any special effort to put himself in 
such a state. He is then asked to attend to 
some stimulus, such as reading or singing, or 
to the monotonous beats of a metronome. 
"When the reading is over, the patient with his 
eyes shut is asked to repeat it and tell what 
comes into his mind during the reading, or 
during the repetition, or immediately after. 
This should be carried out in a very quiet 
place, and the room, if possible, should be 
darkened so as not to disturb the patient and 
thus bring him out of the state in which he has 
been put. As modifications of the same 
method, — the patient or subject is asked to 
fixate his attention on some object, while at 



Multiple Personality and Amnesia 347 

the same time listening to the beats of a 
metronome, the patient's eyes are then closed, 
he is to keep very quiet, while the metronome or 
some other monotonous stimulus is continued. 
After some time, when the patient's respiration 
and pulse are found somewhat lowered, he 
is asked to concentrate his attention on a sub- 
ject closely relating to the symptoms of the 
malady or to the submerged subconscious state. 
In other words, the patient is in a hypnoidal 
state favorable for the emergence of subcon- 
scious experiences." 

"The patient again may be asked to be very 
quiet, to move, or to change position as little 
as possible, and is required to look steadily 
into a glass of water on a white background 
with a light shining through the contents of 
the glass; a mechanism producing monotonous 
sounds is set going, and after a time, when the 
patient is observed to have become unusually 
quiet, he is asked to tell what he thinks in 
regard to his symptoms. In other cases it is 
sufficient to put the patient in a relaxed condi- 
tion, have his eyes shut and tell him to think 
hard of the particular dissociated states." 

"Now in working with the method of hyp- 
noidization I have often observed in using it 
that the patient at first tries to concentrate his 
attention and seems to fall into slight hypnosis, 
but pretty soon he is fully awake. In closely 
watching this condition I found that at first 



348 Psychopathology of Hysteria 

the patient attempted to fixate his attention, 
then lost control over it. His attention being- 
relaxed he fell into a sleep-state, ont of which 
he emerged again, owing to the partial presence 
of the idea of the necessity of concentration of 
the attention, as well as to the partial watch- 
fulness present. It is this alternate and incom- 
plete relaxation and concentration of the atten- 
tion that keeps the patient on the borderland 
of wakefulness, hypnosis and sleep. In some 
cases the hypnoidal state passed into hypnosis. 
Thus in one of my cases, V. F., at first I ob- 
tained only hypnoidal states, but after some 
time the hypnotic state gained ground and the 
subject passed into typical hypnosis and finally 
into a somnambulistic state. In other cases I 
have observed that preliminary to the passing 
into the hypnotic state proper a short interval 
is present which may be regarded as a hyp- 
noidal condition. In many other cases the 
patient is not in the hypnoidal condition, but 
still there are phemomena present which re- 
mind one strongly of the hypnotic state. " (Jour, 
of Abnormal Psychology, vol. 3, p. 15.) 

With a limited number of patients dissociated 
memory complexes can be reproduced by means 
of crystal vision and automatic writing. When 
one suggests to a hysteric who is a good 
visualizer that while she looks into a crystal, 
or some other object, she will see taking place 
the particular event of which one may hap- 



Multiple Personality and Amnesia 349 

pen to be desirous of obtaining information, 
it is probable that the suggested visual hal- 
lucinations will occur. Of the successful ap- 
plication of crystal vision in the Beauchamp 
case one instance is most interesting because it 
demonstrates the conservation, and the possibil- 
ity of reproduction, in this case at least, of 
memories of events which happened during 
febrile delirium: 

"Miss B. looked again into the globe; she 
saw a room with a bed in it. There was a 
figure in the bed; the figure threw off the bed- 
clothes and got up. Miss B. exclaimed, 'Why, 
it is I!' (Appeared rather frightened at what 
she saw, but went on to describe it, largely in 
answer to my promptings, such as, 'Go on, r 
'What do you see?' etc.). She saw herself 
walking to and fro, up and down the room. 
Then she climbed on to the window sill which is 
the deep embrasure of a mansard roof. Then 
she climbed outside the window and from the 
sill looked down into the street. It was night — 
the street lamps were lighted, there was also 
the gaslight in the room. As she looked down, 
she felt dizzy. Here Miss B. turned away 
frightened, saying she felt dizzy as if she were 
standing there. She soon continued. She saw 
her vision-self throw into the street below an 
inkstand, which she had just seen herself pick 
up before climbing on to the window sill. Miss 
B. was again obliged to stop looking because 



350 Psychopathology of Hysteria 

of dizziness. After a time she returned to the 
globe. She saw herself go back into the room 
and walk up and down; the door opened, and 
she jumped into bed and lay quiet. Miss L. 
(a friend) entered, went out, and returned 
several times ; brought a poultice which she put 
on Miss B.'s chest; Miss B. herself remaining 
quiet. Then Miss L. went out and Miss B. got 
up and took the poultice, rolled it up into a 
little bunch and hid it in a corner, putting a 
towel over it. Here the experiment ended."* 

"Miss B. stated, on being questioned, that 
she could not remember any incident like the 
vision, excepting that she recognized the room 
as the first one she occupied when she came 
to Boston four or five years ago. It was in the 

top story of a house on street; she was 

ill there, and Miss L. took care of her. But 
she did not remember ever having climbed on 
to the window, or having thrown an inkstand, 
or any of the incidents of the vision. She could 
throw no light on the affair." 

"Deep hypnosis: B. Ill appeared. With 
great vivacity and amusement, B III ex- 
plained the whole scene. * She ' had pneumonia 
and was delirious; and 'She' imagined 'She' 
was on the seashore and was walking up and 
down on the sand. This was why ' She ' walked 



*"Miss L., a physician, has confirmed her own part 
in this scene and the geneial facts of the illness as 
she knew them. Another physician had diag-nosed 
pneumonia." 



Multiple Personality and Amnesia 351 

up and down the room, and 'She' stuck her 
toes in the carpet thinking it was sand. There 
were rocks there, and the window sill was one 
of them, and when 'She' climbed out upon the 
window sill 'She' thought 'She' was climbing 
upon a rock, and 'She' took up a stone, as 'She' 
thought, and threw it into the sea. This was 
the inkstand that 'She' threw into the street. 
Then when 'She' took the poultice and hid it 
in the corner, 'She' thought 'She' had buried 
it in the sand. Ink had been found in her 
shoes, but 'She' had not poured ink into her 
shoes, but her hand shook, and 'She' had 
spilled it into her shoes. Miss L., seeing the 
inkstains, had inferred that Miss B. had poured 
the ink into the shoes, and had told Miss B. so. 
B. Ill was highly amused at all the mistakes of 
Miss B.'s delirium." (The Dissociation of a 
Personality, 1906). 

The method of association reaction time ex- 
periments is a valuable psychoanalytic means 
whose elaboration we owe mainly to Jung, and 
whose interpretations are based largely upon 
the theories of Freud. The clinical application 
of the method consists in timing the intervals 
between stimulus test words, which are called 
out by the physician, and the responses of the 
patient with the associated words which first 
arise in her mind. The normal reaction time 
varies somewhat in different individuals, but 
the average is about one or two seconds. The 



352 Psychopathology of Hysteria 

physician makes up a list of about one hundred 
test words and then obtains the patient's reac- 
tion time to each. On analyzing the results it 
is found that the reaction time of some of the 
tests is much greater than the patient's aver- 
age — the reaction has been inhibited. Careful 
study of these "complex indicators" is produc- 
tive of a certain amount of information con- 
cerning either submerged complexes which have 
been "touched" by the test words, or conscious 
complexes whose existence the patient does not 
desire to reveal. If necessary a second list can 
be analyzed of significant words which the re- 
sults of the first experiment suggest to the phy- 
sician. 

Whenever a test word "touches" a hidden 
complex, or one that is associated with a strong 
feeling tone, the reaction time is much length- 
ened, or the reaction is incomprehensible, or the 
patient does not react at all, and, when ques- 
tioned, asserts that she has forgotten the test 
word. This last is particularly interesting in 
that it illustrates the tendency for words or 
ideas which have become associated with a sub- 
merged complex themselves to become dissoci- 
ated. When the same list of words is gone over 
a second time the patient usually fails to react 
with the same words to those stimulus words 
whose reactions were inhibited the first time. 
Often significant reactions are obtained without 
retardation of the reaction time providing that 



Multiple Personality and Amnesia 353 

the complex which has been "touched" is not 
submerged nor particularly unpleasant. On the 
other hand, retardation always occurs when the 
patient not wishing to reveal some conscious idea 
deliberately substitutes a word for the one which 
arises in her mind. 



CHAPTER X 

Hysteric Temperament — Suggestibility 
— Delusions — Insanity — Theories 

THE mental state of hysteric persons 
usually deviates markedly from what 
might be considered normal standards, 
and it is upon this continuous patho- 
logic foundation that many of the paroxysmal 
1 ' accidents " develop. Strictly speaking it is 
not logical to speak of certain selected groups 
of symptoms as the mental state of hysteria, for 
the study of the disease as a whole is merely a 
study of morbid mental states and their physi- 
cal expression. Moreover, there is no group of 
distinctive mental "stigmata" whose detection 
enables one positively to pronounce the presence 
of what is termed hysteria, or by reason of 
whose absence hysjeria can be eliminated. 

By no means do all hysterics present a com- 
mon type of temperament. In the same man- 
ner that the character of all other symptoms 
depends almost entirely upon the personal 
equation, so also does the temperament of a 
hysteric. The mental characteristics of a 
phlegmatic German who develops manifesta- 
tions of hysteria certainly will not be like those 
of an emotional Frenchman. There are, never- 
theless, certain kinds of mental peculiarities 

354 



Hysteric Temperament 355 

which are encountered so frequently among 
cases of hysteria as to deserve being designated 
the hysteric temperament. Though possessing 
some significance when present, the absence of 
what is called the hysteric temperament is not 
to be considered as evidence of any value in 
the elimination of hysteria. 

Judgment and cerebral inhibition being de- 
ficient, and sensibility to many kinds of im- 
pressions being increased, the hysteric is 
inclined to exhibit imperfect self-control in that 
her reactions to mental stresses are exag- 
gerated or perverted. Consequently, emotional 
outbursts may occur that, according to usual 
standards, are excessive in character and 
duration and which normally would not be 
justified by their exciting causes. Briefly, the 
reactions of the individual to his environment 
are excessive and perverted. 

Emotional instability and morbid sensitive- 
ness naturally result in rapid variations in 
moods: at one moment laughing, the hysteric 
may be crying the next. The same factors are 
apparent in the "hysterical" attacks of alter- 
nate crying and laughing. Not all emotional 
outbursts, however, are significant of hysteria 
just as no other one symptom is indicative of 
the disease, and, on the other hand, the emotion- 
al displays occurring in undoubted hysteria 
should not be considered evidences of repre- 
hensible wilfulness. Neither are they always 



356 Psychopathology of Hysteria 

the result of immediate faulty parental super- 
vision; the blame, if any, should rest with the 
decreased power of inhibition that is sympto- 
matic of the disease. 

In hysteria, the faculty of mental representa- 
tion is greatly increased and gives rise, among 
other symptoms, to varying moods and to 
romancing. The patient passes much of her 
time in weaving stories around little incidents 
that arise, and usually she places herself in the 
star role. If the faculty of visualization is well 
developed these day dreams are visualized. 
One patient asserted that when meditating she 
heard her own thoughts, and that she could 
hear answering voices if she desired. While 
romancing she visualized the scenes of her 
dramas and held silent conversations with the 
actors. The faculty of mental representation 
being so highly developed in those who are 
good auditives and visualizers, it would be 
interesting to know the frequency with which 
they become victims of hysteria as compared 
with those who do not possess these powers. 
Indulgence in romancing is decidedly harmful. 
Frequently, not only delusions and other 
psychic symptoms, but also physical projec- 
tions such as anaesthesia and paralysis may be 
traced directly to some day dream which had 
supplied the material that subsequently be- 
came fixed by unconscious autosuggestion. 

Being extremely sensitive, hysterics brood 



Hysteric Temperament 357 

over supposed wrongs, neglect, or derision, and 
often some of their complaints seem to be based 
upon no other cause than morbid desire to 
provoke attention and sympathy. In an adult 
this represents reversion to similar tendencies 
of children. After being rebuked, or spanked, 
often the child tells his parents that they don't 
care for him, and that they would act dif- 
ferently if he were sick. Going off by himself, 
he vividly pictures himself seriously ill with 
his friends and relatives grouped around his 
bed carefully tending to his wants, grieving 
about his condition, and expressing remorse for 
their former neglect and ill treatment. The 
only difference between these day dreams of 
the child and those of the hysteric depends 
upon the fact that in the latter the idea of 
illness is sufficient to induce actual representa- 
tion. 

Morbid desire for sympathy and to be the 
center of attention is a prominent trait of many 
hysteric patients, so that, excepting as subjects 
of clinical demonstration, nothing pleases them 
more than to be carefully examined and 
studied by physicians. So great may become 
this desire that the hysteric may hesitate at 
nothing to gratify the propensity. Thus 
feigned haematemesis, anorexia, fever, and self 
inflicted mutilations by no means are rare. To 
reiterate, such malingering should not be 
regarded other than as a symptom, and as such 



358 Psychopathology of Hysteria 

it has nothing in common with simulation by a 
non-hysteric. 

The effects of desire for sympathy and atten- 
tion exhibited by one of Wilson's cases is inter- 
esting. (Modern French Conceptions of Hys- 
teria, Brain, 1910, p. 315.) A girl of 15, wish- 
ing "to be coddled" like her sister, who had a 
deformed foot resulting from injury, at first 
unconsciously copied the deformity and later 
drove a large tack into her foot with conse- 
quent infection and other complications. At 19 
she cut her hand in order to make the school 
mistress love her more. The following year the 
mother was ill in bed and this aroused in the 
patient the desire to be ill, too, and to receive 
sympathy. Thinking "it would be nice to have 
spinal disease" she rubbed nitric acid up and 
down her back. A year later hysteric para- 
plegia appeared associated with analgesia ex- 
tending up to the waist and also involving the 
whole of one side. At this time she was de- 
tected breaking off needles in her anaesthetic 
side. 

The self infliction of pain in McArthur's case 
was due to a different motive; one which is not 
rare, but which is seldom carried to such an 
extent. (Jour, of Nervous and Mental Disease, 
1911, p. 425.) "When 17 the patient scratched 
the end of her little finger with a pin. Recur- 
ring abscesses followed, and, after three years, 
the finger was amputated. A year later an- 



Hysteric Temperament 359 

other finger became similarly involved, and this 
one, in its turn, was amputated at the end of a 
year. After this the other fingers, the hand, 
and segments of the forearm, and arm were 
sacrificed progressively for recurrent abscesses. 
Finally, at thirty-two, even the scapula and the 
outer half of the clavicle were excised. At this 
time Briquet attacks and sensory deficits were 
present. It developed that pain in the wound 
produced an orgasm, and for this reason the 
patient purposely irritated the wound and pre- 
vented it from healing. Psychoanalysis of this 
case would be interesting in determining how 
the association of pain and orgasm came about 
originally. 

Egocentricity, whether this be active, or sim- 
ply a passive form that permits the patient to 
accept sacrifices, frequently results from desire 
to command sympathy and attention. No mat- 
ter how altruistic the individual may have been 
moderate or excessive disregard of the feelings 
and rights of others is very apt to develop after 
the onset of hysteria. The hysteric malingerer 
does not seriously concern herself about the addi- 
tional expense that her simulation may impose 
upon the already drained finances of her family ; 
neither does she consider the long hours of de- 
privation of sleep that she may occasion those 
who are caring for her during some more or less 
grave illness which she is simulating. In the 
words of Sidis "innate cussedness" in itself may 
make a psychic trouble worth studying. 



360 Psychopathology of Hysteria 

Often the patient is an intelligent woman 
whose home shows abundant evidence of refine- 
ment and artistic tastes. Conversing with her 
we note that she is quiet, very charming, and 
that she possesses a widely varied, and somewhat 
more than superficial, fund of knowledge. Really 
it is a pleasure to chat with her. When the con- 
versation turns to herself, and particularly to 
her bodily health, she continues to smile pleas- 
antly while describing in an intelligent manner 
her various symptoms, for each of which she has 
a logical explanation. Touching upon her his- 
tory she volunteers the information that she has 
never been hysterical or emotional; in fact just 
the reverse. Protesting all the while about any 
inconvenience which she may occasion yet she 
continues to detain us with much unnecessary 
and irrelevant detail. Constantly we see indi- 
cations that while apparently she strives con- 
tinually to be most considerate of others still 
those with whom she is associated are subjected 
to much inconvenience and unnecessary, but 
willing, self sacrifice. In spite of what ordi- 
narily would be considered distressing and seri- 
ous manifestations she does not seem to be con- 
cerned over these. Indeed, they afford her an 
opportunity for conversation which is just as 
impersonal as if she were discussing the health 
of a friend. Such a patient, one whose descrip- 
tion by no means is overdrawn for it is that of 
an actual case, is typical of patients encountered 
in the better classes of society. 



Hysteric Temperament 361 

In the sense that this term is usually em- 
ployed morbid introspection does not belong to 
the symptomatology of hysteria. Rather as an 
evidence of the clinical syndrome known as 
psychasthenia is the non-insane obsessive intro- 
spection. Neither are fear and worry to be met 
with in the infrequently encountered cases of 
uncomplicated hysteria. The typical hysteric is 
absolutely unconcerned about her condition, no 
matter how serious this may appear to be, and 
the only reason why she may attend to her symp- 
toms is because of the sympathy and attention 
which they may provoke in others. Instead of 
worrying over their condition some patients 
seem almost to derive pleasure from their various 
manifestations. These are the confirmed hys- 
terics who delight in having a new set of symp- 
toms or in presenting aggravations of former 
ones each time the physician calls. Their mal- 
ady is superior to any physician. 

It is difficult to hold the attention of a hys- 
teric. Instead of attending to the necessities 
of the moment attention is diverted into other 
channels, or is concentrated upon some revery. 
This characteristic helps to explain some of the 
inconsistencies revealed during examination. 
When testing hearing with a watch the ticking 
is not consciously perceived because the patient 
is really not attending to the perceptions. 
Frequently, normal persons, who have not been 
attending to what has been said, ask that a 



362 Psychopathology of Hysteria 

remark be repeated, yet, in the same breath, 
they show that they have heard by responding 
before we have had a chance to comply with 
the request. Unless attention is deeply con- 
centrated upon some one object normally it is 
possible consciously to perceive a number of 
different kinds of sensory impressions while at- 
tending to a variety of acts. Thus the teacher 
lectures to his class while demonstrating manu- 
ally, "keeping an eye" on the delinquencies of 
some one or more members, and perceiving a 
number of other extraneous sensory impres- 
sions. 

According to Janet the field of consciousness 
of the hysteric is so contracted that she is 
unable to attend to different impressions and 
acts at the same time. Although Janet's views 
of Retraction of the field of consciousness 'cannot 
be accepted in their entirety, yet many of 
the manifestations of hysteria closely resem- 
ble peculiarities of normal absent-mindedness. 
Does not the absent-minded individual ignore 
all perceptions unrelated to the absorbing in- 
terest of the moment? According to Bibot, 
voluntary or artificial attention is a product 
of education — of civilization — and it is grafted 
upon spontaneous or natural attention. (The 
Psychology of Attention, Open Court Pub. Co., 
1890.) Hence we may look upon the hysteric's 
deficiency of voluntary attention as one of the 
many types of reversion, exhibited in hysteria, 



Hysteric Temperament 363 

towards the mental traits of the child, or, 
phylogenetically, towards those of the savage. 

In addition to instability of attention the 
hysteric exhibits a tendency towards inter- 
ference with, or unconscious prevention of, 
more or less automatic acts when her attention 
is directed to the manner in which they are 
performed. This is but an exaggeration of the 
normal, for most of our acquired reflex or auto- 
matic actions are best executed unconsciously. 
The normal interference of conscious attention 
is often to be observed in the gait of the 
student as he ascends the steps to the stage in 
order to receive his diploma, and is often appar- 
ent in the actions of the actor new to the stage. 
This fact is so well known that even the lay- 
man remarks that the individual is self-con- 
scious. It is shown also, as Jastrow has re- 
marked, by the difficulty which many experi- 
ence in the attempt to swallow a pill. Al- 
though those conditions which are called atten- 
tion neuroses — stammering, insomnia, astasia- 
abasia, attention tremors, etc. — may occur in 
hysteria the majority are symptomatic of 
psychasthenia. 

Volition is not impaired in hysteria; it is 
perverted. The patient is unable consciously 
to will a paralyzed arm to move because sub- 
consciously a greater effort of volition is exer- 
cised in order to maintain the paralysis. Let 
us regard the apparent diminution of will 



364 Psychopathology of Hysteria 

power as being due to the antagonistic effects 
of contrary and subconscious acts of volition. 
Instead of being decreased it would seem, in 
fact, that there occurs actual increase of will 
power. Surely it requires an unusual amount 
of perverse application of the will in order that 
deliberate mutilations can be self inflicted for 
no other reason than to elicit sympathy and 
attention. Consider, too, the intensity of pur- 
pose necessary to starve oneself to death as so 
frequently occurred consciously in cases of 
hysteric simulation of anorexia, and subcon- 
sciously in the essential, non-simulated ano- 
rexias of hysteria. 

Abnormal Suggestibility. The only con- 
stant, and therefore characteristic, symptom 
or stigma of hysteria, the one which, in reality, 
is at the foundation of the great majority of 
other manifestations, is abnormal increase in 
susceptibility to suggestion, whether this be to 
the suggestions of others or of self. Just as it 
is believed that the ultimate analysis of thought 
and of all other forms of mental activity re- 
veals the dependency of these processes upon 
sensory impressions — immediate or remote — so 
that which is designated autosuggestion must be 
consequent upon an external stimulus. Clinically 
the source of the autosuggestions of hysterics 
often is found to be the unintentional sugges- 
tions of others. Thus the autosuggestion 
responsible for psychic contagion is really a 
manifestation of heterosuggestion. 



Hysteric Temperament 365 

Expectant attention is the equivalent of 
autosuggestion. If one attends to any function 
while expecting certain variations to occur, is 
not autosuggestion implied ? By autosuggestion 
we do not mean that in the absence of some 
good reason a patient deliberately thinks: "My 
arm will become paralyzed/' Rather than 
such a gross misinterpretation of the term as 
applied to the genesis of symptoms of hysteria, 
let us say that there is subconscious belief, 
engendered by more or less logical reasoning, 
that the arm may become paralyzed. In a 
hysteric patient the idea of a symptom only too 
readily is evoked, and the process by which 
actual representation occurs through the 
agency of these ideas is designated autosugges- 
tion. To those who have not experimented 
with hypnosis — and practical knowledge of the 
phenomena capable of being brought about by 
suggestion is almost essential in order to grasp 
the mechanism of production of symptoms of 
hysteria — free use of the term autosuggestion 
is apt to convey the impression that the process 
is mysterious, and but little understood, and 
that the term is too comprehensive; in fact, 
that it is but a convenient cloak for real ignor- 
ance of the mechanism which is being described. 

For the purpose of illustrating the quite 
reasonable manner in which an autosuggestion 
is originated, there is no better example than 
that afforded by the use of a prism in a case of 



366 Psychopathology of Hysteria 

suggested visual hallucination. When a prism 
is placed before one eye of a subject in whom 
one has succeeded in producing by suggestion 
a visual hallucination, not only are the images 
of actual objects doubled, but also the hal- 
lucinatory image is reduplicated. Such an ex- 
periment reveals the delicacy of autosugges- 
tion. To call the process by which this re- 
duplication occurs autosuggestion is just as 
gross a means of explanation as to apply the 
same term to similar processes occurring con- 
stantly in hysteria. The fault lies in the im- 
possibility to designate briefly a process which 
is so complex and so delicate as that of auto- 
suggestion, but to one who is conversant with 
hypnotic suggestion the term autosuggestion 
is quite intelligible. 

It has been contended that the "suggestion- 
ists" attempt to explain everything by sugges- 
tion without being able to explain suggestion 
itself. Neither can physicists tell us just what 
electricity is, yet they manage to understand 
it sufficiently to enable others to make use of 
its advantages. As we do possess knowledge of 
the effects of intentional suggestion in hypnosis 
and hysteria, there does not seem to be any 
reasonable objection to descriptions of the pa- 
thogenic effects of accidental suggestion in those 
who are known to be abnormally susceptible to 
this agent, even though we cannot tell just what 
it is or how it acts. 



Hysteric Temperament 367 

To understand better the pathogenic possi- 
bilities of suggestion, let us digress in order 
briefly to study normal suggestibility; for all 
people are susceptible to suggestion of some 
form or other, even though habitually they may 
seem to exhibit opposition to external influ- 
ences. The great numbers who developed 
manifestations of hysteria among those who 
attended the early religious revivals, and 
among Indians during ghost dances, is indica- 
tive of the suggestibility of mankind. Among 
many other similar instances which could be 
adduced in reference to the heightened 
suggestibility characteristic of a mob is one 
related by De Ooncourt: During the Franco- 
Prussian war, thousands of men were convinced 
that they had seen posted on a pillar of the 
Paris Bourse an announcement of French 
victories — some even had read the bulletin — 
when, in reality, the incident was one of a 
mutually suggested visual hallucination. 

Normally, a suggestion tends irresistibly to 
arouse ideation in the same manner that all 
thought is dependent upon present or former 
sensory impressions. Just as emotions always 
find expression in some form of physical 
activity, so man tends to act in accordance 
with his ideas. It follows, then, that sugges- 
tions are disposed to become realized. To con- 
trol this tendency, cerebral inhibition is 
brought into play — the suggested idea is criti- 



368 Psychopathology of Hysteria 

cally examined, and if not compatible with the 
interests of the individual, the suggestion is not 
acted upon. Confidence, on the other hand, 
leads to inhibition of criticism. Even though 
contrary to our own convictions, we often 
accept and carry out the suggestions of another 
who possesses our confidence. Thus, we are 
not constantly on the defensive when obtaining 
information from those in whom we have 
confidence; while, on the contrary, we refuse 
to believe all the statements of one whom we 
distrust, especially if critical examination of his 
assertions results in doubt concerning their 
probability. Confidence, then, increases sug- 
gestibility, and distrust inhibits this normal 
characteristic of the human mind. 

Children are highly suggestible because they 
do not possess sufficient knowledge to enable 
them to examine critically suggested ideas 
before accepting them as facts. They have 
confidence in most everyone because they have 
not yet learned that much of our vaunted 
knowledge, and much of what is taught them 
as facts, later must be subjected to critical 
revision or entirely discarded. In fact, anyone 
who is ignorant of a subject necessarily must 
accept the statements of one who knows more 
than he about the matter. The student would 
only be confused were his teacher to qualify 
his statements and to discourse learnedly on 
theories and exceptions. Hence he is given 



Hysteric Temperament 369 

a skeleton of dogmatic facts. After he has 
acquired rudimentary knowledge of the sub- 
ject, the student discovers that he must discard 
some of these fundaments, and so elaborate the 
revised whole that finally he possesses a con- 
ception which is largely the product of his own 
efforts. 

Because of their confidence, and being 
unaccustomed to subject to criticism what they 
are told, children may accept the most improb- 
able statements. So readily does the imagin- 
ative child confuse his own day dreams with 
reality that it is not surprising that another 
person unintentionally may cause him to be 
the victim of hallucinations and delusions. On 
more than one occasion a child has testified 
about some crime when his testimony was 
solely the result of a suggestive form of ques- 
tioning, or of a " third degree" examination. 
It is not unknown, also, for false confessions of 
crimes to be obtained in the same manner — 
even with adults — and with most disastrous 
consequences. 

The combative, self-reliant man who takes 
pride in asserting that he is not open to the 
influence of others is actually less suggestible 
than usual. Still, even he can be successfully 
acted upon with suggestion, providing that he 
is unaware of the fact. What might be called 
a general law of suggestibility provides that 
normally, and often abnormally, the more 



370 Psychopathology of Hysteria 

veiled and indirect the suggestion the greater 
the chance of realization, while during hyp- 
nosis, and in some cases of hysteria, usually 
the more direct and forcible the suggestion the 
more apt is it to be accepted. In other words, 
normally a suggestion which is recognized as 
such always tends to arouse opposition. If 
one should remark to a hysteric : ' ' Your arm 
is paralyzed and without feeling, " it is prob- 
able that she would deny the assertion at once. 
But subject the same patient to the usual 
suggestive form of physical examination which « 
reveals to her that the physician expects to find 
loss of sensibility as part of her disease, and 
commonly anesthesia will be discovered at the 
time, or afterwards. 

Spontaneously in psychasthenia, and often 
artificially as a result of hypnotic suggestion, 
there may be strenuous opposition to a sug- 
gested idea, yet the conscious rebellion is over- 
come by subconscious acceptance. It is char- 
acteristic of a psychasthenic to be fighting con- 
tinually against obsessions. While walking 
along the street a psychasthenic sees a fruit 
stand and the thought flashes into his mind of 
the shocking consequences which would ensue 
were he caught stealing an orange. Though 
the fear of stealing an orange and the impul- 
sion to do so are recognized as foolish, yet, as 
much as he strives, he cannot dismiss these 
obsessions from his mind. The resistance of the 



Hysteric Temperament 371 

psychasthenic to his obsessions is due to 
knowledge concerning the source and nature of 
his symptoms} On the other hand, the hysteric 
is unaware of the reason for her symptoms be- 
cause the whole mechanism is subconscious.'- 
The difference between the two is well illus- 
trated by the difference in the manner of ful- 
fillment of a post-hypnotic suggestion which the 
patient recognizes as such, and of one whose 
source is veiled by amnesia. 

What is suggestion? The definition of such 
a comprehensive word is as impossible as the 
definition of hysteria. The whole question of 
suggestion resolves itself into the necessity for 
each to have his own conception just as all who 
have dealt with the subconscious have their 
own useful but widely varying conceptions of 
the subject. Bernheim comprehensively de- 
fines suggestion as the act by which an idea is 
awakened and accepted. Sidis writes: "By 
suggestion is meant the intrusion into the mind 
of an idea ; met with more or less opposition by 
the person; accepted uncritically at last; and 
realized unreflectively, almost automatically." 
(Psychology of Suggestion, 1889, p. 15.) Mere- 
ly as a working hypothesis let us say that nor- 
mal suggestibility consists in the critical ac- 
ceptance of suggested ideas providing that they 
promote, or are compatible with, the welfare of 
the individual. A state of abnormal suggesti- 
bility is in evidence when by reason of an ex- 



372 Psychopathology of Hysteria 

cessive amount of confidence, or of diminution 
in the power critically to examine and to reject 
what is suggested, a person accepts and acts 
upon ideas which do not conserve his own 
interests. 

A good example of the genesis of a symptom 
in the suggestion of another is shown by a 
patient who, in addition to other symptoms. 
for several years had been afraid to go to 
sleep. The origin of the fear was unknown 
to her, yet it was found, during hypnosis, that 
following the sudden death of her father a 
"clairvoyant" friend in whom she had im- 
plicit faith had told her to take good care 
of herself as her turn was coming soon. The 
shock of her father's death being a good 
foundation, this suggestion became fixed, and 
before a month had passed she developed 
"nervous prostration" and was confined to bed 
for a few weeks. Her fear of going to sleep 
was based upon fear that she would not wake 
in the morning. 

Prince's Beauchamp and B. C. A. cases con- 
tain many examples of the mechanism of auto- 
suggestion in the production of various mani- 
festations. In the section dealing with astasia- 
abasia one instance already has been men- 
tioned. The following one is described by the 
co-conscious personality B. of the B. C. A. case: 
"C. once had a visual hallucination of Dr. 
Prince, because I was thinking of him. She 



Hysteric Temperament 373 

was thinking of entirely different matters, but 
I was thinking that if it were not for Dr. 
Prince I might, perhaps, stay all the time, and 
was wondering why it was that I did not go 
away somewhere ; why it was that I felt bound 
to keep C.'s appointments with him, etc. As I 
was thinking all this C. suddenly saw Dr. 
Prince standing before her. He was so real 
that she spoke his name, saying, 'Why, Dr. 
Prince!' " (Jour, of Abnormal Psychol., vol. 3, 
p. 311). 

Hallucinations, Delusions, Sub-conscious 
Fabrication. By reason of the increased power 
of mental representation, hallucinations, delu- 
sions and subconscious fabrication are exceed- 
ingly common in hysteria. Even during the 
minor emotional crises hallucinations not only 
occur, but their character determines largely 
the nature of the attack. Thus Sallie S. hal- 
lucinates her dead child during her seizures, and 
Parker's patient experiences a fetid taste before 
each convulsive attack. 

Through the agency of hypnotic suggestion 
it is not difficult to induce hallucinations either 
during the hypnotic state, or after resumption 
of the usual state of consciousness. Ordinarily 
those in whom hypnotic hallucinations can best 
be secured are the good visualizers or auditives. 
Otherwise the subject states that the music 
rims through his bead, but he doesn't actually 
hear it, or that the picture only rises in his 



374 Psychopathology of Hysteria 

mind. The successfully induced hallucination 
corresponds to those of hysteria while the less 
successful ones resemble the mental imagery of 
the good visualizer who can project the mental 
image of a person and make the projected 
image act as desired, but who recognizes that 
the image is only the product of his own mind. 

What has been called a negative hallucination 
is the absence of conscious perception of what 
subconsciously is perceived. Hysteric amauro- 
sis and other varieties of disturbances due to 
lack of conscious perception of sensory impres- 
sions, particularly when the deficit is systema- 
tized, furnish examples of this condition. 

When the memory of the hallucinations or 
delusions of a hysteric crisis, or of some other 
state of alteration of consciousness, is carried 
over to the usual state and the patient relates 
the subjective experiences as actual occurrences 
the condition is known as subconscious fabrica- 
tion. A common source of subconscious fabrica- 
tion is the day dream. So vivid may be the 
mental imagery of the day dream that its con- 
tent may become fixed and elaborated in the 
same manner that the habitual liar finally be- 
lieves his own lies. Whatever the origin, the 
patient really believes in his fabrications and he 
relates them without having any intention to de- 
ceive. It is unfortunate, however, that generally 
the fabrications are looked upon as intentional 
lies, and it is on this account that the hysteric is 



Hysteric Temperament 375 

supposed to be deceitful and thoroughly unre- 
liable. 

On two occasions one young hysteric dreamed 
that two men had entered her room and had 
cut off her hair. The third morning her window 
was found open and her hair, cut off about six 
inches from the scalp, was discovered on the 
floor. She told the family and myself that she 
did not know how her hair had been cut off, but 
that she thought someone must have entered her 
room during the night. During the hypnotic 
state she admitted, without any hesitation, hav- 
ing cut off her hair because she did not like it 
so long. Formerly the hair had been cut every 
summer, but this year, in spite of her remon- 
strances, it had not been done. Dreams being 
largely based upon antecedent events and 
thoughts, it is not surprising that after unsat- 
isfactory discussions over having her hair cut 
the little girl should have experienced dreams in 
which her desire was fulfilled. The dreams prob- 
ably acted as suggestions and as reinforcements 
to her desire with the result that she got up at 
night and cut off her hair. Being in a somnam- 
bulistic condition at the time she did not remem- 
ber after waking in the morning what had 
occurred. Consequently, she drew upon her 
memories of the former dreams in order to ex- 
plain the event. 

Suppose that while romancing a patient appro- 
priates and applies to herself some incident 



376 Psychopathology of Hysteria 

which happened to a friend. Later she may 
relate the exaggerated occurrence as having 
happened to herself. Gordon has reported a case 
in which the patient acted in accordance with 
the belief that her relatives were trying to kill 
her. These persecutory delusions were the out- 
come of a novel which she had read. On an- 
other occasion she recounted with a wealth of 
detail the events of her marriage and honeymoon 
abroad. This fabrication, too, was the result of 
personal application of material derived from 
another novel. (Amer. Jour, of the Med. Sci- 
ences, 1906, 1,830.) 

In a case of dissociation of the personality 
recorded by Angell, the patient narrated the most 
remarkable and elaborate history of periods for 
which, in reality, he was amnesic. Afterwards 
it was found that his account was due to falsi- 
fication of memory; the patient really believing 
at the time what he related. This patient filled 
in the gaps in his memory with elaborate detail 
just as a subject who has carried out a post- 
hypnotic suggestion gives a specious reason for 
the act which he affirms was performed of his 
1 ' own free will. ' ' When hysteric patients relate 
improbable tales, or ones which are known to be 
untrue, one must not be mislead into believing 
that the stories represent deliberate lying whose 
object is to stimulate interest and wonder. 

Hysteric Insanity. There is still less of a 
dividing line between ordinary hysteria and 



Hysteric Temperament 377 

what is termed hysteric insanity than there is 
between sanity and insanity. 

Whether one decides that a case is one of 
hysteria or of hysteric insanity depends entirely 
upon the intensity and fixity of the more obvious 
psychic manifestations, and upon the degree to 
which they incapacitate the patient from enter- 
ing into external relations. 

As a matter of fact the majority of hysteric 
patients present many of the symptoms upon 
which a diagnosis of insanity is ordinarily based. 
Thus transitory hallucinations, delusions, and 
states of delirium and of confusion are exceed- 
ingly common. Leaving out of consideration the 
possibility of insanity plus manifestations of 
hysteria, if one chooses to recognize such a com- 
bination, then there really is no such condition 
as hysteric insanity just as hysteric paralysis is 
not actual paralysis; either of these manifesta- 
tions being merely a psychic duplication of more 
serious conditions. All the clinical types of 
insanity, however, may be counterfeited so ver- 
itably that often a mistake in diagnosis may be 
made and remain uncorrected until the patient 
has been under observation for a considerable 
period — perhaps in a hospital for the insane. 

On one occasion I signed the commitment 
papers of a young girl who presented what 
were considered to be indubitable manifesta- 
tions of alienation, only to have her discharged 
over two months later with the report that dur- 



378 Psychopathology of Hysteria 

ing the whole of her stay in the institution she 
had been entirely free from any symptoms of 
insanity. Until her admission to the hospital 
this patient, nevertheless, had exhibited many 
fixed delusions of a paranoid type. Frequently 
she had threatened to kill her father, to set fire 
to the house, and to commit suicide. On two 
occasions she had attempted suicide with gas. 
Moreover there was good reason to believe that 
she had entertained homosexual relations with 
her sister. In consequence of fear that the pa- 
tient would commit some serious act of violence 
after her release from the hospital, her parents 
refused to allow her to remain at home so she 
was admitted to a charitable institution. 

It must not be thought that patients with 
hysteric insanity do not become violent, for 
such is not the case. In a comprehensive paper 
containing reports of a large number of cases 
of hysteric insanity Woodman (Jour, of Nerv. 
and Ment. Dis., Jan., Feb., and Mar., 1908.) 
remarks: "On the other hand the symptoms 
are of wide variety and may be of extreme 
violence. It is a mistake to think that because 
a patient is hysterical that all the mental 
symptoms are shallow and ephemeral and 
scarcely are real at all. A hysteric often acts 
under profound emotion and may do any rash 
or violent act that profound emotion suggests, 
as for example, Case No. 5, in the present series, 
took with suicidal intent all her sleeping pow- 



Hysteric Temperament 379 

ders at once, and recovered because the total 
dose was not lethal rather than because her 
suicidal act was consciously inadequate. More 
or less determined and entirely real efforts at 
suicide are decidedly common." 

As illustrated by the Bachman case even 
murder may be committed during hysteric in- 
sanity. This case being so unusual and so in- 
structive a somewhat detailed account seems 
warranted. Following a period of careful study 
of the Bible, at the instigation of a friend who 
had recently been converted, Bachman de- 
veloped a state of religious ecstasy with visions. 
Through psychic contagion his wife, sister, 
and brother-in-law became similarly affected. 
Among the phenomena experienced by this 
small group of worshippers who made their 
own interpretations of the New Testament, 
were the "second coming of Christ," and the 
expulsion of devils from their bodies by the 
Spirit of God. 

During the height of religious frenzy ac- 
companying the efforts of casting out of devils 
Bachman killed his five-year-old niece. This 
act was the consequence, he stated, of impul- 
sions, which he felt came from God, to kill the 
child, thus driving out the devils and sending 
her to heaven instead of to hell. 

Three weeks after the tragedy he related the 
facts of the murder without hesitancy or 
emotional display except for slight exaltation 



380 Psychopathology of Hysteria 

when discussing his religions views. The only 
regret he had was that the others had aban- 
doned the new creed. Having been declared 
insane by a commission in lunacy he was ad- 
mitted to the State Hospital for the Insane at 
Norristown. Not until eight months after the 
deed did he show any change in his views, and 
then with distinct emotion he talked of the 
crime stating that he must have been influenced 
by a higher power. 

"In a conversation held nearly a year after 
the ones above reported," writes W. W. Rich- 
ardson, the author of the paper of which the 
above account is an abstract, (The Case of 
Robert Bachman, Jour, of Nervous and Mental 
Diseases, 1910, p. 689.) "he stated that he and 
his wife had lived in a very narrow circle all 
their lives and that he had never realized how 
ignorant they were of life and the relations of 
things until he came to Norristown. He said 
he had known nothing of insanity nor what 
insane people were like. Since coming here he 
had had much opportunity to learn what in- 
sanity meant and to compare himself with 
others whom he knew to be insane. While he 
still felt that his act was not wrong for the 
reason that his motives were pure and that he 
had no evil thoughts against the child, still he 
tacitly admitted the probability that he was not 
mentally sound when he killed the child. At 
this conversation it was noted also that he was 



Hysteric Temperament 381 

under a considerable emotional strain and that 
he felt the subject a painful one, thus showing 
a striking contrast to his early readiness of 
speech about the matter. ' ' 

' ' Since his admission to the institution he has 
been a model patient in every respect, working 
faithfully and efficiently wherever placed and 
showing much enjoyment in the day's work, 
especially when out-of-doors or about ma- 
chinery, for which he has an aptitude. He is 
extremely tactful and courteous in all his rela- 
tions with both patients and officials. He never 
discusses his troubles with anyone unless ques- 
tioned and then only with physicians.' ' 

The writer believes that there are many rea- 
sons why Bachman should not be considered a 
religious paranoiac. He considers the diagnosis 
difficult but concludes that "in view of the 
epidemic nature of the whole manifestation, the 
absence of delusions at present and the tend- 
ency toward recovery of a normal mental tone, 
a diagnosis of hysterical insanity of the epi- 
demic type seems the only one justifiable." 
Having carefully searched the literature Rich- 
ardson was able to find one case ("Case of 
Chas. F. Freeman, of Pocasset, Mass.," by C. 
F. Folsom, M. D., Amer. Jour, of Insanity, vol. 
40, p. 353.) which was identical in many re- 
spects with his own, and a second one, reported 
by Dr. Henry M. Hurd, (Annual Report of the 
Eastern Michigan Hospital for Insane for the 



382 Psychopathology of Hysteria 

year 1884) which showed points of resemblance. 

Though the prognosis may usually be con- 
sidered to be good it must be remembered that 
hysteric insanity at times is only a forerunner 
of real insanity, and that it is not uncommon 
to discover what appear to be manifestations 
of hysteria in patients whose actual insanity is 
in a stage of evolution. 

Theories. Before taking up some of the 
views of Janet and of Freud let us examine in 
abstract some interesting biologic conceptions 
held by Jelliffe. (N. Y. Med. Jour., May 16, 
1908.) For Jelliffe hysteria in an adult con- 
sists in a collection of primitive modes of re- 
action. Ontogenetically, hysteric individuals 
are matured children; phylogenetically, they 
are instructed savages. The mental character- 
istics of hysteria comprise instability — particu- 
larly emotional instability — suggestibility, nega- 
tivism, and egocentricity. Desire to be the 
centre of attention causes the savage to strut 
about in feathers and paint, while in hysteria 
the same egocentricity, here a manifestation of 
atavism, is the motive for romantic accusations, 
self inflicted mutilations, and for theatrical 
attempts at suicide. Practically all the physi- 
cal signs result from abnormal suggestibility. 
Lack of logical judgment is the chief character- 
istic of the normal mentality of the child, and 
as hysteria represents reversion towards the 
infantile type this characteristic leads to a sys- 



Hysteric Temperament 383 

tern of autosuggestion which may terminate in 
profound disturbances of personality. "The 
importance of moral causes in the development 
of hysterical states cannot be overestimated. 
From this point of view we may consider 
hysteria as a series of abnormal reactions of 
the individual to the exigencies of life. These 
abnormal modes of reaction are often the conse- 
quence of the fetters, or the obstacles which the 
moral and social order impose upon the expres- 
sion of the natural tendencies of man and show 
themselves the more strongly the closer the 
man approaches the child viewpoint.' ' The 
association of hysteria with organic disease 
strictly accords with the "hypothesis that the 
superior individual is one who by intelligence 
and by training has developed past his hyster- 
ical infancy, or youth, but let intercurrent 
disease reduce his resistance, or sink the level 
of his nervous tension, as Janet would express 
it, and a natural reversion to primitive traits 
is to be expected." Beside symptomatic hys- 
teria and the evolutive type representing only 
an accident in the mental evolution of the in- 
dividual, or of the species, there is a third group 
of cases composed of degenerative hysterias — 
of hysteria developed upon a distinct neuro- 
pathic heredity. 

Man strives to place all phenomena upon 
a physical basis, and among these has been 
included hysteria. Applying to hysteria the 



384 Psychopathology of Hysteria 

hypothesis of Rabl-Riickhard it has been pro- 
posed to explain the condition by assuming that 
the underlying pathologic mechanism is one of 
dendritic retraction. Beside the fact that this 
theory is but feebly supported by facts, and 
that it has been rejected in many authoritative 
quarters, its application to hysteria does not 
explain in a satisfactory manner the pathology 
of the disease, no matter how attractive at first 
it may seem. "Where does the retraction take 
place in case of psychic anaesthesia? What 
cells are isolated? Sensory impressions from 
the anaesthetic region not only are perceived, 
as shown elsewhere, but apperception occurs, 
and an intelligently directed motor response 
may take place. Therefore, the cortical cells 
which receive the impulses are not isolated and 
retraction of dendrites would have to involve 
over half of the cells of the brain, thus pro- 
ducing a true double personality. It would be 
difficult to explain how retraction of dendrites 
could produce a case of double consciousness m 
which the morbid personality possessed the 
memories of both states while the first one is 
limited to its own. Finally, retraction of den- 
drites not only must be capable of being in- 
duced by suggestion, more or less independent 
convictions, etc., but of being dispelled by the 
same factors. 

The most important of the early advances in 
the study of hysteria was the recognition by 



Hysteric Temperament 385 

Jules Janet, in 1888, of the disintegration of 
personality which occurs in the disease. About 
the same time Pierre Janet began to develop the 
psychopathology of hysteria upon a basis of sub- 
conscious fixed ideas, or of dissociated memory 
complexes. According to his conception of the 
disease the most characteristic manifestation is 
somnambulism; a condition dependent upon 
cleavage from the usual state of consciousness of 
a system, or of systems, of memories. When 
somnambulistic crises result from the activity of 
a single dissociated system of ideas the condition 
is termed monoideic somnambulism. Polyideic 
somnambulism and fugues result from dissocia- 
tion of a number of systems, and multiple per- 
sonality, the ultimate of dissociation, represents 
massive disintegration of personality. The many 
other attacks of hysteria are merely abortive or 
imperfect types of somnambulism. 

Janet believes that the deficiencies of con- 
scious perception are capable of being explained 
by assuming that as a result of retraction of 
the field of consciousness there occurs a kind of 
absent-mindedness ; being unable to attend to 
many kinds of sensory impressions the patient 
gets into the habit of not consciously attend- 
ing to the ones which are least important to her. 
When the habit becomes fixed anaesthesia, amau- 
rosis, etc., result. He defines the disease as "a 
form of mental depression characterized by the 
retraction of the field of personal consciousness 



386 Psychopathology of Hysteria 

and a tendency to the dissociation and emanci- 
pation of the systems of ideas and functions 
that constitute personality." 

According to Babinski the stigmata are always 
the effect of suggestion; usually of medical 
origin. He defines hysteria as a psychic state 
which renders the patient susceptible to sugges- 
tion. It is manifested principally by primary 
disorders and accessorily by secondary disturb- 
ances. What characterizes the first is the possi- 
bility of reproducing them by suggestion with 
rigorous exactitude in certain subjects and of 
making them disappear under the exclusive in- 
fluence of persuasion. What characterizes the 
secondary disturbances is that they are strictly 
subordinated to the primary disorders. 

In 1893 a new epoch in the study of hysteria 
was initiated by the contribution of Breuer and 
Freud, and at present Freud's highly elaborated 
conception of submerged complexes and the re- 
sults of their activity is the one which is rapidly 
finding acceptance in neurologic circles. The 
theories both of Freud and of Janet have been 
drawn upon extensively in the composition of 
the body of this work; in this section it is in- 
tended merely to recapitulate some of the more 
important and less complicated of Freud's inves- 
tigations. 

Before taking up some of his original theories 
let us first quote from the Peterson and Brill 
translation two sentences which indicate Freud's 



Hysteric Temperament 387 

agreement with the results of researches com- 
menced by the French school: " . . . the 
splitting of consciousness, so striking in the 
familiar classical cases of double consciousness 
exists rudimentarily in every hysteria, and that 
the tendency to this dissociation, and with it 
the tendency towards the appearance of abnor- 
mal states of consciousness which we compre- 
hend as 'hypnoid states,' is the chief phenom- 
enon of this neurosis. " "A persistent hyster- 
ical symptom therefore corresponds to a projec- 
tion of this second state into a bodily inner- 
vation otherwise controlled by the normal 
consciousness. A hysterical attack gives evi- 
dence of a higher organization of this second 
state, and if of recent origin it signifies a 
moment in which this hypnoid consciousness 
gained control of the whole existence, and 
hence we have an acute hysteria, but if it is 
a recurrent attack containing a memory we 
simply have a repetition of the same." 

Normally the effects of an emotion which has 
not been adequately externalized may be 
worked off by means of subsequent verbal 
expression — giving vent to one's feelings. Or 
these deleterious effects may be neutralized by 
association with antagonistic ideas. For ex- 
ample, the painful memories of an accident 
are rendered inocuous by association of ideas 
with its fortunate termination. When, as a 
reaction of defense, an individual strives to for- 



388 Psychopathology of Hysteria 

get the painful memories of some experience 
and thus fails adequately to express the emo- 
tional feeling, the memory complex of the 
occurrence may become submerged, or disso- 
ciated. The motives for suppression of various 
ideas and mental states may be consequent 
upon moral training, social environment, or 
upon the painful nature of the ideas them- 
selves. All ideas which tend to bring the disso- 
ciated complex into the stream of conscious- 
ness themselves are dissociated as secondary 
reactions of defense, with the result that the 
original complex becomes surrounded by a 
continually increasing number of associated 
constellations until the whole, by a process of 
conversion, may react upon the patient by pro- 
ducing any of the various manifestations of 
hysteria. These manifestations are merely 
symbolic representations of what has been 
repressed, or they may be fixed or recurring 
symptoms derived from phenomena which were 
accidentally associated with the emotional 
experience which served as the exciting cause. 
"When tracing back, by means of psycho- 
analysis, the different levels of psychic 
traumata from which symptoms were derived, 
Freud found that invariably they led back to 
sexual experiences of early childhood. Inas- 
much as perpetuation of the species is depend- 
ent upon the sexual instinct, this force is most 
obtrusive and far reaching; its influence being 



Hysteric Temperament 389 

perceptible in much of our activity, even 
though commonly this is not fully appreciated. 
Having such a vast number of ramifications, 
it is but natural that this instinct should exert 
a tremendous influence in the genesis of psy- 
choneuroses. 

Sexual modesty having been acquired by 
precept, and by education, normal sexual long- 
ings are consciously repressed as immoral and 
reprehensible, with the consequence that ulti- 
mately the dissociated ideas may become con- 
verted into physical symptoms, or into obses- 
sions, just as the force of the instinct may be 
converted into increased professional activity 
and thus expressed. Morbid anxiety and other 
obsessions are deviations due to repression of 
sexual desire from its natural mode of expres- 
sion: they are transformed reproaches for 
pleasurably accomplished sexual activity of 
childhood. Hysteria is the outcome of a con- 
flict between libido and sexual repression; 
the symptoms being a compromise between 
two antagonistic psychic systems. Apparent 
lack of sexual impulses is due to successful 
repression of the sexual instinct, and is accom- 
panied by commensurate substitution of some 
other kind of expression. The psychic 
traumata from which symptoms of hysteria 
are derived, are experiences concerning the 
sexual life of the child, even though the excit- 
ing cause be some emotion of a non-sexual 
nature. 



390 Psychopathology of Hysteria 

"When consciousness is at its normal mini- 
mum — during sleep — inhibition is so reduced 
that suppressed complexes assert themselves. 
Dreams, therefore, are elaborated and fanci- 
ful expressions of desires which have been 
consciously repressed as incompatible with the 
ego. Being such, investigation and intelligent 
interpretation of the content of dreams leads 
to valuable information concerning submerged 
complexes. 

In support of his views regarding sub- 
conscious pathogenic memory complexes, Freud 
has made careful studies of the normal activity 
of complexes which do not rise to the level of 
consciousness, and he has shown that much of 
our psychic activity is dependent upon motives 
of which we are ignorant. "We act from 
motives Of which consciously we are unaware, 
and in our ignorance we ascribe our actions to 
motives which, in reality, are fictitious. When 
we are unable to recall a familiar name, and in 
its place others arise, only to be rejected, the 
whole is not a matter of chance. Analysis of 
such incidents shows that the name cannot be 
recalled because of its association with some 
disagreeable ideas which have been repressed. 
For example, Freud was unable to recognize a 
name which he came across in one of his 
account books. The subconscious motive — dis- 
covered later — consisted in the fact that he 
had overlooked a pelvic sarcoma while treat- 
ing the patient for symptoms of hysteria. 



Hysteric Temperament 391 

An individual turns a deaf ear to any argu- 
ments concerning his religious convictions be- 
cause, as he thinks, it would be sacrilegious to 
enter into any such discussions. He is not aware 
of any other and more fundamental reason for 
his disinclination to argue the point, yet the real 
incentive is his own suppressed tendency to ques- 
tion the rationality of his superficial beliefs. 
That a person can perform an act as a conse- 
quence of the activity of a submerged complex 
and yet believe that he is acting in accordance 
with some other and entirely different motive is 
not as improbable as at first it may seem. The 
controlling influence of subconscious complexes 
is best illustrated by the manner in which an 
individual accounts for an act which was really 
imposed upon him by post-hypnotic suggestion. 
The following incident related by Jastrow is a 
good example of unconscious falsification of 
motives s 

"In a garden, on a hot summer day, when all 
energies are relaxed, a mother requests her 
daughter to get a certain book from the study- 
table. The request seemingly goes unheeded, 
for the daughter continues to loll in the ham- 
mock. Yet presently she goes to the house and 
returns with the book and the explanation, 
'Mother, I happened to see your book, and 
thought you might want it.' Her surprise at 
the laughter that greeted her remark sufficiently 
attested her unawareness of the source of the 



392 Psychopathology of Hysteria 

impulse upon which she had acted." (The 
Subconscious, 1906, p. 134.) 



For further information concerning Freud's work 
the following English translations, reviews, and 
other papers upon which I have been largely de- 
pendent may be recommended: 

Freud: Selected Papers on Hysteria, trans, by A. 
A. Brill, 1909. 

Freud: Three Contributions to the Sexual The- 
ory, trans, by A. A. Brill, 1910. 

Brill: Freud's Conception of the Psychoneuroses, 

, Med. Record, Dec. 25, 1909. 

/Brill: The Anxiety Neuroses, Jour, of Abnormal 
Psychology, vol. 5, p. 57. 

Putnam: Recent Experiences in the Study and 
Treatment of Hysteria at the Massachusetts Gen- 
eral Hospital; with Remarks on Freud's Method 
of Treatment by "Psycho-Analysis." Jour, of 
Abnormal Psychology, vol. 1, p. 26. 

Putnam: Personal Experience with Freud's Psy- 
choanalytic Method, Jour, of Nervous and Men- 
tal Disease, 1910, p. 657. 

Putnam: Personal Impressions of Sigmund Freud 
and His Work, with Special Reference to His 
Recent Lectures at Clark University, Jour, of 
Abnormal Psychology, vol. 4, pp. 293 and 372. 

Coriat: A Contribution to the Psychopathology of 
Hysteria, Jour, of Abnormal Psychology, vol. 6, 
p. 33. 

Jones: Psycho-Analysis in Psychotherapy, Jour, of 
Abnormal Psychology, vol. 4, p. 140. 

Jones: Rationalization in Every-day Life, Jour, of 
Abnormal Psychology, vol. 3, p. 161. 

Jones: The Psycho-Analytic Method of Treat- 
ment, Jour, of Nerv. and Ment. Dis., 1910, p. 285. 

Hart: Freud's Conception of Hysteria, Brain, p. 
339, 1911. 

In connection with Freud's theories the follow- 
ing papers also are of great interest: 

Jung: Psychology of Dementia Praecox, Peterson 
and Brill trans., 1909. 



Hysteric Temperament 393 



Brill: Psychological Factors in Dementia Praecox, 
Jour, of Abnormal Psychology, vol. 3, p. 219. 

Jones: Remarks on a Case of Complete Auto- 
Psychic Amnesia, Jour, of Abnormal Psychology, 
vol. 4, p. 218. 

Onuf: Dreams and Their Interpretation as Diag- 
nostic and Therapeutic Aids in Psychopathology, 
Jour, of Abnormal Psychology, vol. 4, p. 339. 



CHAPTER XI 

Diagnosis, Prognosis and Treatment 

THE diagnosis of hysteria — a disease 
which is capable of mimicking closely 
practically all other diseases, and which 
occurs so frequently in association with 
organic maladies — often must be attended with 
great difficulties. Not only are the symptoms 
of hysteria innumerable, but constantly one en- 
counters unique cases presenting symptoms 
which never before have been described, and 
which can be recognized as manifestations of 
this disease only by analysis of the psychic fac- 
tors which enter into their production. Provid- 
ing that an adequate examination has been made, 
the diagnosis of typical cases is easy; but such 
cases are uncommon. 

In males, in children, and in the aged, the 
diagnosis may be encompassed with greater 
difficulties than usual. In children, and in 
males, the disease is prone to be monosymp- 
tomatic, and frequently these patients do not 
present much evidence of what is designated 
the hysteric temperament. In the aged symp- 
toms of hysteria often mask those of organic 
disease, and besides, the fact that the patient 
is beyond middle life is apt to lessen the chances 
of ascribing to hysteria symptoms which are 
really due to this disease. 

394 



Diagnosis, Prognosis and Treatment 395 

Often the diagnosis is made merely on the 
evidence afforded by emotional instability, and 
general "crankiness"; and this may be ac- 
complished without first having eliminated the 
possibility of co-existence of some other, and 
perhaps more serious, disease whose treatment 
is of far greater importance. Quite commonly 
the general practitioner makes the mistake of 
considering as hysteric the more or less inten- 
tional emotional outbreaks — ' ' hysterics ' ' — of 
pampered children and wives ; disturbances cal- 
culated to break down the resistance of those 
who oppose their vagaries. And, on the other 
hand, as a result of such a conception of the 
disease the manifestations of frank hysteria too 
often are regarded as those of organic disease. 
Ordinarily there is far greater chance of mis- 
taking for organic disease the many kinds of 
paralysis, contractures, convulsions, etc., than 
of making errors in the recognition of mani- 
festations of actual organic disease. Besides 
being essential, thorough examination not only 
will decrease the unwarranted frequency with 
which the diagnosis hysteria is abused, but it will 
enable one rigidly to exclude, and the necessity 
for this cannot be too greatly emphasized, or to 
recognize the coexistence of, organic disease. 

As suggestion is at the foundation of most 
hysteric "accidents" the physician should con- 
stantly be on guard in order not to develop new 
symptoms by reason of a faulty technique of 



396 Psychopathology of Hysteria 

examination, and, in the treatment of patients, 
not to prolong by an injudicious amount of at- 
tention the duration of symptoms which already 
are present. Naturally the existence of psy- 
choneuroses does not prevent the occurrence of 
other diseases, so that the diagnosis hysteria is 
never complete unless these either have been 
recognized or excluded. Infrequently it may 
be impossible to decide definitely whether a 
case is one of hysteria or of organic disease, and, 
in these cases, it may be necessary to keep a pa- 
tient under prolonged observation before a posi- 
tive diagnosis can be made with any degree of 
accuracy. 

Analysis of dispensary and private records 
shows that hysteria is about one-third as 
frequent as psychasthenia, and that the sexual 
incidence in hysteria is about M : F : : 1 : 3, 
while in psychasthenia the ratio is almost 
equal ; males being slightly in excess. It should 
be added, however, that many cases which were 
classified as psychasthenia might be designated 
by others as cases of neurasthenia, hysteria, or 
hypochondriasis. 

In attempting to separate into different func- 
tional diseases various abnormal manifestations 
of psychic origin, it should be remembered that 
we are merely classifying in an arbitrary man- 
ner, and purely for clinical purposes, different 
types of abnormal reactions which necessarily 
must vary to the same degree that even nor- 



Diagnosis, Prognosis and Treatment 397 

mal individuals vary. Being characterized by 
perverted reactions of the individual to his 
environment, any attempt symptomatically to 
classify the psychoneuroses must be arbitrary 
and unsatisfactory. 

"What are called hysteria, psychasthenia, 
neurasthenia, hypochondriasis, and multiple 
personality, are only clinical syndromes, and 
as such their differentiation is often difficult, 
if not impossible. Hence, cases which might 
be considered neurasthenia by one physician 
would be designated hysteria by another, and 
psychasthenia or hypochondriasis by a third. 

The impossibility of arriving at a satisfac- 
tory symptomatic classification of psychoneuro- 
sis corresponds with the abandoned attempts 
symptomatically to classify insanity. Such at- 
tempts must fail for the same reason that it 
would be impossible to classify mankind 
according to the manner in which individuals 
react to various environmental stimuli. "It is 
the men of science who cut separate pieces out 
of a whole that nature has made continuous." 
(Janet). 

The differential diagnosis of the psycho- 
neuroses still further is complicated by the fre- 
quent occurrence of cases into whose composi- 
tion enter symptoms of hysteria and of psychas- 
thenia, or of hysteria and neurasthenia. As 
careful study resolves most, if not all, cases of 
neurasthenia into hysteria and psychasthenia the 



398 Psychopathology of Hysteria 

present tendency is to abolish neurasthenia as a 
clinical entity. In fact, Prince considers the 
neurasthenic state to be one of the stigmata of 
hysteria. Many of the cases which formerly 
were classified under the name hypochondriasis 
— of which we hear but little in these days — 
are now regarded as types of psychasthenia. In 
view of the unsatisfactory nature of the usual 
symptomatic classifications, still further tend- 
ency towards unification has been evidenced by 
the proposal that we should abandon attempts 
to classify the functional neuroses, and that all 
of these cases be grouped under the term psy- 
choneuroses. Such a careless mode of solving, 
or rather of escaping from, the problem would 
be just as much an instance of retrogression as 
would be relinquishment of attempts to classify 
alienation and merely to be satisfied with the 
term insanity. 

The only value possessed by the diagnoses 
hysteria, psychasthenia, neurasthenia, and hypo- 
chondriasis, is the fact that these terms convey 
some idea of the character of the manifestations 
presented by a patient. Having the same end 
in view, however, one might proceed indefinitely 
to divide these conditions into gastric neuroses, 
cardiac neuroses, sexual neuroses, innumerable 
varieties of phobias, etc. 

Enough has been said in describing the indi- 
vidual symptoms of hysteria to render unneces- 
sary their detailed differentiation from those of 
organic disease. As combinations of symptoms 



Diagnosis, Prognosis and Treatment 399 

of hysteria may mimic closely other diseases it 
is advisable, however, briefly to consider several 
of these. Excluding epilepsy, probably the most 
difficult diagnostic problem consists in the dif- 
ferentiation of some cases of hysteria from mul- 
tiple sclerosis. In both diseases symptoms often 
appear suddenly in an emotional young woman, 
and, after having persisted a varying length of 
time, disappear just as abruptly. In each dis- 
ease there is no fixed order of appearance of 
symptoms; neither is there much limitation to 
symptomatic possibilities. In some cases of mul- 
tiple sclerosis which appear to be uncomplicated 
by hysteria the patient may display emotional 
outbursts and evidences of what constitutes the 
classic hysteric temperament. These manifes- 
tations are supposed to be due to plaques of 
sclerosis in the optic thalamus. As multiple 
sclerosis is so generally complicated by hysteria 
the ability to make a positive diagnosis of hys- 
teria never excludes the possibility of co-exist- 
ence of multiple sclerosis, or, in fact, of any other 
organic disease. In doubtful cases typical 
organic kind of exaggeration of the tendon 
reflexes, presence of true ankle clonus, of the 
Babinski sign, and of atrophic changes in the 
optic discs, always signify the presence of mul- 
tiple sclerosis, or of some other organic ner- 
vous disease. 

Acute and chronic abdominal disease may be 
closely mimicked by hysteria, and even though 



400 Psychopathology of Hysteria 

this functional neurosis is known to be present 
the difficulty of excluding appendicitis, gastric 
ulcer, etc., may be great. The fact that the 
patient is known to be a hysteric is very apt to 
lead to greater diagnostic uncertainty by reason 
of fear of being biased and thus ascribing to 
the hysteric element symptoms of some serious 
organic disease. A valuable differentiating 
sign consists in the fact that hysteric patients 
usually breathe more deeply when pressure is 
exerted over a painful abdominal region, while 
in organic abdominal disease the actual pain 
resulting from localized pressure prevents deep 
respiration and the patient either momentarily 
ceases to breathe, or the respirations become 
quite shallow. 

When it is impossible to eliminate positively 
organic disease it is essential to treat the patient 
as though the condition were organic, and if 
the necessity for an operation appears to be 
absolute, then it is preferable to operate un- 
necessarily on several cases of hysteria rather 
than to allow one case of hysteria to die be- 
cause actual appendicitis, for instance, arose as 
a neglected complication. 

"When hysteric patients simulate disease in 
order to command attention and sympathy 
curious diagnostic problems may arise. Among 
these may be mentioned those patients with 
hysteric vomiting who simulate gastric ulcer by 
means of vomiting blood which they have ob- 



Diagnosis, Prognosis and Treatment 401 

tained by causing epistaxis and then swallow- 
ing the blood. 

Course and Prognosis. In my opinion hys- 
teria is rarely cured. The manifestations of 
the disease can be removed easily in most cases, 
and the morbid temperament of the patient 
somewhat modified, but all the accidents con- 
tinue to exist as potentialities which may be- 
come actual at any time, providing that suf- 
ficient provocation occurs. The "cure" of these 
cases resembles the "cure" of pulmonary tu- 
berculosis in that symptoms of either disease 
may be caused to subside, and the underlying 
predisposition diminished, but we well know 
that both of these conditions have become mere- 
ly latent. 

Provided that the patient has not instituted 
legal proceedings, monosymptomatic hysteria 
resulting from injury is much more amenable 
to treatment than other forms of the disease in 
adults. If such patients come under intelligent 
treatment soon after the onset, the symptoms 
almost invariably can be removed without dif- 
ficulty. If the symptoms have existed for a long 
time, then they may have become so fixed as to 
be more or less permanent in spite of the most 
prolonged and careful treatment. Ordinarily, 
the longer a symptom has existed the more 
resistant it is to treatment. 

With the pure forms of hysteria occurring in 
children, the results of treatment are eminently 



402 Psychopaihology of Hysteria 

satisfactory, and the ultimate prognosis is much 
better than with adults. The reason for this is 
evident when one stops to consider that the 
minds of children are in the stage of evolution, 
and, being plastic, are easily influenced. The 
harmful results, too, of faulty education and 
environment can be corrected more readily 
before emotional instability has become habitual. 

Without treatment symptoms may vanish 
during an emotional shock, or in the absence of 
any apparent cause. Sometimes, after having 
resisted all forms of treatment, they disappear 
spontaneously as the result of most curious and 
trivial incidents. Wilson mentions just such 
a case. (Brain, 1910, p. 313). A young 
woman gradually developed mutism that was 
completely resistant to treatment. Long after 
leaving the hospital she discovered that she had 
been right in an argument she had had with 
her aunt before the mutism had developed. In 
her elation she cried out: ''I'm right,'' and 
then: "Oh, I've spoken, auntie!" Wilson re- 
marks that from that moment her recovery was 
complete and lasting. 

Some patients avail themselves of their dis- 
ease in order to obtain their own ends, and un- 
der such circumstances the physician works at 
a disadvantage. The cases which are most re- 
sistant to treatment are those in which the 
disease appears after middle life, and those 
subjects of traumatic hysteria whose recovery 



Diagnosis, Prognosis and Treatment 403 

to a great degree is prevented by protracted 
legal proceedings whose "favorable ' ' outcome is 
dependent upon the severity and hopelessness 
of their condition. Even though the latter sin- 
cerely desire to be cured of their manifestations 
the fact alone that a lawsuit is in progress, to 
say nothing of the suggestive effects of the 
prognostically unfavorable testimony to which 
they are exposed, is most conducive to the 
indefinite continuance of the disease. If par- 
alysis can be induced by suggestion alone cer- 
tainly it can be caused to become more or less 
permanent when the patient hears an expert 
testify that such may be the case. 

The prognosis is bad, also, in those who de- 
velop hysteria upon a foundation of decided 
neuropathic heredity, and whose environment 
is unfavorable, as usually it is in these cases. 
Even though their symptoms may be readily 
removed, recurrence of old, or the development 
of new, manifestations sooner or later is al- 
most inevitable. 

In arriving at a prognosis the apparent 
severity of a symptom is not a criterion. Often 
the most severe symptoms are controlled much 
more readily than those which seem almost 
negligible. The removal of a convulsive 
tendency, for instance, is much less difficult 
than the cure of a long standing functional 
headache. If patients do not receive any treat- 
ment usually the manifestations gradually or 



404 Psychopathology of Hysteria 

suddenly disappear to be replaced by others, or 
the patient may remain comparatively free 
from obvious symptoms for an indefinite time. 
Often, too, a symptom which has been produced 
by one emotional shock will disappear suddenly 
after a second one. It should be remembered 
that not infrequently major symptoms have 
persisted for many years in spite of treatment. 
More than one hysteric afflicted with a psychic 
paraplegia, for instance, has been confined to 
bed many years, or, in fact, until death oc- 
curred. As far as death is concerned the prog- 
nosis of hysteria is excellent. Almost the only 
symptom which is capable of causing death is 
hysteric anorexia ; the patient dying from star- 
vation. Such fatalities, formerly so frequent, 
would not be permitted to occur at present. 

Prophylaxis. The prophylaxis of hysteria 
is little more than the application of cor- 
rect methods of education — using this term in 
its most comprehensive sense. By a process of 
hardening, predisposed children should be edu- 
cated psychically to react in a normal man- 
ner not only to the usual stresses of life, but 
to the more severe psychic insults to which all 
are exposed. Most essential is the develop- 
ment of proper realization of true relations with 
the outside world; to cause the individual to 
appreciate that she is only a unit in a vast 
system. 

As the parents of nervous children are often 



Diagnosis, Prognosis and Treatment 405 

nervous themselves the influence of psychic 
contagion should be avoided, if possible, by 
changing the child's environment. If old 
enough she may be sent to a boarding school, 
and thus the beneficial effects of discipline and 
of constant association with many normal chil- 
dren are gained, and, furthermore, she passes 
through experiences which tend to promote self- 
reliance. 

Sedentary habits should be discouraged, and 
a healthy out of door life instituted, especially 
in connection with the usual games of children, 
even if these are rough. The great difficulty 
with predisposed children and young adults is 
that they are usually carefully shielded from 
unpleasant experiences and their lives made too 
calm. By reason of such fostering care any 
trivial difficulties to which they are unaccus- 
tomed tend to arouse emotional reactions which 
are out of proportion to the exciting cause. In- 
stead of being carefully shielded and kept "tied 
to the apron strings" of their mothers, who too 
often are hysteric themselves, children should 
be exposed, carefully at first, to the troubles of 
childhood and of maturity and thus accustomed 
to disappointments, to knocks, and to the neces- 
sity of recognizing the rights of others. 

Instead of condoning emotional outbreaks 
the child should be taught to control her 
temper and to realize, too, that desires cannot 
always be indulged — that many must be relin- 



406 Psychopathology of Hysteria 

qnished. In fact one should strive constantly 
to engender emotional stability, and to discour- 
age selfishness and desire for sympathy. In 
place of making much ado about trivial injuries 
and thus stimulating desire for sympathy, 
parents should be instructed to treat these with 
judicious neglect, and never to sympathize un- 
duly with the child over what are negligible 
and inevitable minor difficulties of childhood. 

The pernicious habit of relating ghost stories 
to children, and of enforcing obedience with 
threats about the "bogey man," cannot be 
condemned too strongly. Many adults whose 
minds otherwise are not obviously abnormal 
are obsessed with vague fear of darkness, or 
some other phobia of like nature, which can be 
traced back to just such foolish stories. There 
are few factors which are more detrimental 
than abnormal fear, and for this reason it is most 
essential that the child should be brought up 
in a manner which is as devoid as possible of 
elements leading to the development, and to the 
encouragement of fear. Rather a boisterous, 
noisy, and fearless child than a quiet one sub- 
dued by various threats and later to become 
obsessed with morbid fears. 

The practice of reading trashy literature, 
and especially that type of sensational novel 
which is responsible for so much silly sentimen- 
tality, is responsible for the development of 
unhealthy emotionalism and of faulty concep- 



Diagnosis, Prognosis and Treatment 407 

tions which are bound to lead to unnecessary 
disappointments and to lost illusions. Those 
who indulge in this type of literature are the 
very ones who lead sedentary lives, and con- 
sequently, the mischievous effects of such read- 
ing is not so apt to be counteracted by actual 
experiences. It is these young girls who are 
fond of going off by themselves and having day 
dreams in which they figure in unusual and im- 
possible episodes. As these day dreams are 
purely a type of dissociation in which imagina- 
tion is allowed to run riot, the individual is 
encouraging the development of unhealthy sub- 
conscious states which are characteristic of the 
psychoneuroses, and in consequence of some 
emotional disturbance which is greater than 
usual such states may assume some form of 
activity independent of the consciousness of 
what is now a patient. The importance of ro- 
mancing as one of the factors in the genesis of 
hysteria cannot be disregarded. One has only 
to question a number of female hysterics to 
discover that the majority were accustomed to 
the dissipation of day dreaming before the on- 
set of actual hysteria. 

As the shock occasioned by the first appear- 
ance of the menses in young girls who, with 
great injustice, have been kept in ignorance of 
this function, is often the exciting cause of hys- 
teria it is most important that the phenomena of 
menstruation should be fully explained before 



408 Psychopathology of Hysteria 

pubescence arrives. Youths, too, should be in- 
structed concerning the harmless nature of noc- 
turnal emissions and thus saved from the decid- 
edly harmful effects of quack literature ascrib- 
ing disastrous consequences to this normal effect 
of sexual continence. The majority of those 
males who become what are commonly designated 
sexual neurasthenics owe their distressing con- 
dition to inexcusable ignorance concerning noc- 
turnal emissions and to morbid reproaches for 
former sexual offenses. Having proceeded so 
far in educating the young in sexual matters let 
us not stop here. Freud has shown the impor- 
tance of the sexual instinct in the genesis of hys- 
teria, and clinical experience teaches that many 
females develop the disease from occurrences 
which could not have happened had they pos- 
sessed even a rudimentary knowledge of sexual 
matters. 

Physicians are justified on these grounds 
alone in encouraging parents judiciously to in- 
struct their children in the function of repro- 
duction. By means of commencing with plant 
life and then proceeding to reproduction in ani- 
mals this end may be accomplished gradually, 
and in a manner which should be productive of 
nothing but good results. 

The prophylaxis of hysteria is simple in the- 
ory, but, unfortunately, the practical applica- 
tion of preventive measures is another matter. 
Usually the physician has little opportunity of 



Diagnosis, Prognosis and Treatment 409 

attempting to modify or to prevent the develop- 
ment of a predisposition to hysteria, and his 
greatest difficulty is in contending with the well 
meant but prejudicial interference of parents. 

Treatment. He who is not satisfied with 
temporary amelioration of symptoms but who 
seeks to *' ' cure ' ' hysteria, or at least more or less 
permanently to remove manifestations of the dis- 
ease and to modify the underlying psychopathic 
state, must have unlimited patience, a large 
amount of time at his disposal, and a consid- 
erable aptitude for detail. Even though mani- 
festations are sometimes capable of being re- 
moved at once the majority of patients require 
many hours of the physician's time before really 
good results can be expected. To be successful 
the physician must do more than write prescrip- 
tions and give general advice : he must plan out 
just how the patient must pass every hour of her 
time, and then see that she carries out his in- 
structions. Often he will be compelled to find 
some suitable occupation for a woman who is 
unaccustomed to work, and this, it is hardly 
necessary to add, is no small task. In view of 
the fact that to be beneficial the chosen em- 
ployment must interest the patient, the problem 
of occupation is rendered still more difficult. As 
such close supervision of her mode of living 
necessarily renders the patient dependent upon 
the physician it is essential that, as her state 
improves, her self-reliance be developed, and 



410 Psychopathology of Hysteria 

the physician must gradually curtail his at- 
tentions while eliminating himself from her 
life. 

The treatment of actual hysteria naturally in- 
cludes those measures which are of value in the 
prophylaxis of the disease. By reason of the 
psychic nature of the disease routine treatment 
in the majority of the cases must be attended 
with failure. Absolute individualization is in- 
dispensable, for measures which succeed with 
one patient will fail or even aggravate the 
symptoms of another. Thus one patient may 
recover under some therapeutic method whose 
mainstay is rest, while others, who would be 
aggravated by enforced inactivity, might de- 
rive benefit from some carefully selected and 
agreeable form of occupation. The physician, 
then, who treats the patient and not the disease 
is the one who will be most successful in his man- 
agement of the psychoneuroses. 

When examining a supposedly hysteric pa- 
tient one should first eliminate organic disease, 
and then base the diagnosis upon the psychic 
factors of the case while carefully avoiding the 
production of any of the so-called stigmata. 
Going into unnecessary detail in questioning the 
patient about symptoms which might occur in 
hysteria, and too thorough and repeated study 
and clinical demonstration of symptoms which 
have originated in suggestion, are most detri- 
mental. The more carefully one examines into 



Diagnosis, Prognosis and Treatment 411 

the state of the different kinds of sensibility of 
the patient, and the more frequently she is sub- 
jected to such examinations, the more "stig- 
mata" and symptoms will be evident at subse- 
quent visits, while the greater the amount of 
judicious inattention to what are known posi- 
tively to be manifestations of hysteria, the more 
rapidly will these disappear. 

The patient's conception of hysteria is entirely 
different from that of a physician. In her mind 
hysteria is not a disease ; but just willful display 
of emotional outbursts of crying and laughing 
which occur in spoiled women who adopt this 
means to an end. Consequently, having com- 
pleted the examination it is usually unnecessary 
and unwise to tell the patient that she has hys- 
teria. One should evade the issue by calling the 
condition a gastric neurosis, a functional paraly- 
sis, etc., until at least the patient's confidence 
has been gained. 

Unless the physician does not care to have the 
patient return by no means should he inform 
her, as so often is done, that her symptoms are 
only imaginary. Not only is this untrue, but to 
her a splitting headache, a psychic paralysis, an 
amblyopia, etc., are just as real as though these 
symptoms were the product of some organic dis- 
ease. Certainly, to be told that such distressing 
complaints are only imaginary is most insulting 
to her reason, and she justly concludes at once 
that he who utters such an assertion neither un- 



412 Psychopathology of Hysteria 

derstands her case nor his own business. Instead, 
then, of making such a mistake one should strive 
to arouse the impression that her symptoms are 
understood perfectly, and that while none of 
these is phenomenal, or incurable, all have re- 
ceived the same amount of consideration which 
one would bestow, for instance, upon a broken 
leg. 

Naturally, organic disturbances should not 
be overlooked, and when present, attempts 
should be made to ameliorate or to correct 
them, without, however, resorting to unneces- 
sary administration of drugs. Often the 
patient is informed, with an unnecessary 
amount of solicitude, of relatively harmless ab- 
normal conditions of various parts of her body, 
and the state of different organs is discussed 
with an assumption of profound knowledge 
and pseudo-scientific thoroughness. The ad- 
mission of facts which, because of their insig- 
nificance and in view of the abnormal sug- 
gestibility of the patient, should be concealed, 
or at least the inocuous nature of the abnor- 
malities carefully explained, may greatly ag- 
gravate the condition by giving additional 
cause for worry, and by affording the patient 
suggestive data which may lead at first to an- 
ticipation, and then to the genesis of various 
new manifestations of morbid ideation. After 
having been told, for instance, of a well com- 
pensated and practically harmless mitral re- 



Diagnosis, Prognosis and Treatment 413 

gurgitation the patient may commence to group 
around this organic nucleus a number of psy- 
chogenetic symptoms until a "cardiac neu- 
rosis" is developed with all its attendant and 
distressing symptoms. In fact, the majority of 
cardiac and gastric neuroses can be traced di- 
rectly to the injudicious remarks and unneces- 
sary treatment by general practitioners who, 
being satisfied with a diagnosis, either have 
neglected to reassure the patient, or their 
efforts in this direction have been perfunctory 
and ineffective. 

It should not be forgotten, too, that as sec- 
ondary manifestations of abnormal psychic 
states patients frequently present symptoms of 
functional disturbance of the various organs, 
and that as the phychosis improves these dis- 
turbances spontaneously disappear. For in- 
stance, in consequence of depressing emotions 
the digestive fluids fail to be secreted in suffi- 
cient quantities, with the result that fermenta- 
tion and then auto-intoxication appear. When 
having to deal with some of these physical ex- 
pressions, or concomitants, of abnormal mental 
states judicious neglect often is desirable, and 
local treatment, besides being frequently inef- 
fectual, has a decidedly pernicious mental 
effect. 

It is essential that the physician should gain 
the patient's confidence; otherwise, all thera- 
peutic resources will be of little or no avail. 



414 



Psychopathology of Hysteria 



The logical effect of confidence, reinforced by 
the knowledge imparted by the physician of 
the curability of the disease, is to induce the 
patient to anticipate recovery of health. Inas- 
much as expectation of cure usually must pre- 
cede amelioration or removal of symptoms, it 
is of the utmost importance for the physician 
to strive to secure this favorable mental state. 
To this end the patient should be assured that 
no matter how serious her symptoms may seem 
they are without organic foundation and they 
are devoid of the possibility of any physical 
sequellae. Knowing the ease with which the 
manifestations of hysteria usually can be dis- 
sipated one can affirm honestly that under the 
treatment which is about to be instituted her 
symptoms will disappear. 

After having gained the patient's confidence 
the physician might do well to explain the 
psychic origin of the symptoms and the 
mechanism of association of ideas in the pro- 
duction of recurrences of periodic phenomena. 
Caution must be observed in deciding when it 
is advisable to enter into such explanations. 
Unless one has sufficient authority to command 
respect, or unless the patient has perfect con- 
fidence in her physician, she may become in- 
dignant at the attempt to insinuate, as she 
might express it, that her grave symptoms are 
only imaginary. 

When the symptom complex includes symp- 



Diagnosis, Prognosis and Treatment 415 

toms which comprise what is called a cardiac 
neurosis the patient should be assured, after 
careful examination, of the really harmless 
nature of her heart lesion, if she has one. She 
can be told that the majority of people has 
some minor heart murmur, and that although 
the term valvular heart disease popularly im- 
plies a dangerous malady, this interpretation 
is false. In reply to her protest that she gets 
out of breath if she runs up several nights of 
stairs one has only to explain that this is not 
at all unnatural, and that among the normal 
expressions of fear are palpitation, rapid action 
of the heart, and increased respiratory rate. 
Consequently, that when she becomes fright- 
ened about her heart, or at any time when she 
is alarmed, it is inevitable that she should ex- 
perience some cardiac and respiratory symp- 
toms ; that it is only by attending to these man- 
ifestations and fearing grave consequences, by 
reason of ignorance of their meaning, that she 
aggravates what otherwise are normal con- 
ditions. 

In explanation of a gastric neurosis the pa- 
tient can be informed of the effects of mental 
states upon the secretion of digestive fluids as 
demonstrated experimentally by Pawlow. In 
the same manner she can be shown that, in view 
of the circumstances under which she labors, 
many of her symptoms represent normal reac- 
tions of the organism, and that as her compre- 



416 Psychopathology of Hysteria 

hension of the physiology of her body pro- 
gresses these circumstances will be so altered 
that the manifestations no longer can occur. 

Having explained the symptoms and reas- 
sured the patient often it is wise, during sub- 
sequent visits, to treat with judicious neg- 
lect the various manifestations; otherwise, by 
keeping the patient's attention directed upon 
them they are apt to become more fixed. For 
the same reason patients should be told never 
to talk about their ill health, or other troubles, 
and always to discourage others from doing so. 
It is well to instruct her that when anyone in- 
quires about the state of her health she is to 
reply, that she never felt better, and then she 
must change the subject. In fact, one of the 
difficulties with which physicians have to con- 
tend is the decidedly mischievous, but well 
meant, commiseration of friends and rela- 
tives who are constantly reminding the patient 
of her manifestations. It is largely on this ac- 
count that isolation from friends and relatives 
is such an important therapeutic factor. 

Having secured the patient's confidence and 
active assistance, and having induced a state of 
expectant attention, the battle is already half 
won. Almost of equal importance, however, is 
the understanding with members of the family, 
if the patient is treated at home, that the physi- 
cian's authority is to be absolute; that if the 
patient protests about her inability to continue 



Diagnosis, Prognosis and Treatment 417 

with some therapeutic method which she be- 
lieves will aggravate her condition they will 
discourage promptly such ideas and refrain 
from interfering with the management of the 
case. The importance of such an understand- 
ing is great, for if the active assistance of the 
parents is not gained in this respect then the 
physician not only has to contend with the pa- 
tient but also with the whole family. 

When the patient is told that she is to take a 
daily walk, for instance, she complains to her 
parents, or husband, about the impossibility of 
even attempting to do what formerly she was 
utterly incapable of doing. They agree with 
her and promptly the physician is notified that 
it is out of the question for so-and-so to carry 
out these particular directions. Naturally, this 
not only has a bad suggestive effect upon the 
patient, but it materially increases the difficulty 
in enforcing instructions which must be carried 
out or the physician will lose what authority he 
has already gained. For the same reason no 
measure should be proposed unless the physi- 
cian is reasonably certain that it can be suc- 
cessfully carried out, and then, having pro- 
posed it, it is necessary that it shall be suc- 
cessfully instituted. In case the patient re- 
mains at home it is often just as necessary to 
" treat" the family as it is the patient, and one 
must always pay much attention to the instruc- 
tion of those with whom the patient associates 



418 Psychopathology of Hysteria 

in order that they will not sympathize with her. 

Before committing oneself to any form of 
special treatment it is best to ascertain what 
methods have already been employed. Ordin- 
arily one would not care to adopt any therapeu- 
tic measures which have been unsuccessful in 
the hands of others, and to a certain extent one 
would do well intelligently to use those agents 
which the patient regards with favor, for the 
reason that these would be more apt to arouse 
expectation of propitious results. 

"When effectual, the so-called rest cure owes 
its success principally to isolation of the patient 
from his sympathetic friends and relatives, to 
careful supervision of nutrition, and, in fact, 
the whole daily life of the individual, and in a 
large measure to the great impression which the 
whole makes upon the patient, thus tending to 
arouse a hopeful state of mind. Furthermore, 
when members of the patient's family also are 
nervous, as so frequently is the case, the rest 
cure, as well as any other therapeutic method 
which includes isolation, withdraws the patient 
from an environment of unfavorable psychic 
contagion. The recoveries which are secured 
by means of the rest cure are in direct propor- 
tion to the intelligent manner and thorough- 
ness with which the technique is carried out. 
Even more important, however, is the person- 
ality of both physician and nurse. 



Diagnosis, Prognosis and Treatment 419 

Though good results are often obtained with 
the rest cure absolute failure is not uncommon ; 
the patient's condition at the termination of 
the treatment being far worse than before. 
This disposition is greatly increased by poor 
technique, and the aggravation is due to the 
invalidism which failure of this method is par- 
ticularly apt to occasion. Furthermore, the 
rest cure has such a reputation that if it fails 
the patient naturally infers that her disease is 
incurable, and her conviction that such is the 
case goes a great way towards increasing the 
resistance of the disease to treatment. 

Often complaints of fatigue are uttered by 
hysteric patients whose manner of living is 
such that ordinarily fatigue would not be ex- 
pected. If a patient is weary because she can- 
not find any object interesting enough to hold 
her attention, then assisting her in finding some 
employment which will engage her attention, 
and, therefore, which will distract it from 
herself, seems far more rational than putting 
her at rest in bed for at least several weeks. 
If the fatigue is expressed as one which is phy- 
sical, the same method is applicable because 
this exhaustion is only the projection of ennui. 
If a woman becomes tired of the routine of her 
domestic cares, and if she cannot anticipate 
with pleasure the minor difficulties which she 
must face and overcome, then she may feel 
physically exhausted to the extent that she be- 



420 Psychopathology of Hysteria 

lieves herself unable longer to attend to her 
household duties. 

Besides distracting the patient's attention 
from herself the work cure has the additional 
advantage of promoting actual and normal 
physical fatigue with its tendency to insure 
more profound sleep. Exercise in the open 
air also is beneficial, but whatever method one 
adopts as a means of breaking up sedentary 
habits, of distracting the patient's attention, 
and of securing the benefits of muscular activ- 
ity, it is necessary to interest the patient in the 
method or this special treatment not only will 
be fruitless but it may aggravate the condition. 
After the first experience with physical exer- 
cise, or manual training, the patient is very apt 
to rebel in consequence of the unaccustomed 
actual fatigue which has been induced. This 
difficulty can be easily overcome, however, with 
a few words of explanation and reassurance. 

"A form of treatment," as I have written 
elsewhere, "upon which reliance can be placed, 
even in the most intractable cases of psychas- 
thenia, is a course of private instruction in 
tumbling and general gymnastic work under 
a physical director who is especially fitted for 
the handling of neurotic patients. Such a man 
is one who treats his pupils in the same manner 
as an officer would treat a private soldier; one 
who not only will not listen to remonstrances 
from the patient but who will not allow such 



Diagnosis, Prognosis and Treatment 421 

to be made ; who by the very strenuousness of 
bis methods forces the patient to concentrate 
his attention upon a diversity of exercises and 
tumbling which he is expected to do immedi- 
ately upon command and without protest. In 
this manner, not only does the patient receive 
the direct benefit of physical exercise, but he 
acquires self-confidence, learns how to ignore 
his obsessions, and his ego-centricity becomes 
diminished by reason of subjecting himself to 
the will of another." (Jour, of Abnormal Psy- 
chology, vol. 5, p. 1.) 

Providing that the patient can be sufficiently 
interested to carry out the measures in a whole- 
hearted manner any therapeutic method which 
tends to divert her attention from herself there- 
fore should be beneficial. Accordingly, a re- 
stricted form of social intercourse should be 
encouraged; but only with optimistic friends 
who will not be solicitous about the state of the 
patient's health, and who can be depended upon 
to discourage unwholesome topics of conver- 
sation. 

Psychic re-education comprises any explana- 
tory and instructive means which have as their 
aim the education of the patient physically to 
react in a normal manner to any stimulus. 
Naturally these measures include efforts to 
awaken control of the emotions so that they 
and their physical concomitants do not tend to 
occur to an extent which is out of proportion 



422 Psychopathology of Hysteria 

to the end to which they should be normal de- 
fensive reactions. Unless the patient acquires 
emotional stability recurrence of former symp- 
toms, or the development of new ones, is to be 
expected. Too often physicians are satisfied 
with the removal of gross physical manifesta- 
tions of hysteria, and in their pleasure over 
''curing" some distressing condition they over- 
look the important fact that it is only a symp- 
tom which has been removed, and that 
the underlying psychopathic state has not been 
altered. Consequently, it should not be a source 
of surprise that the patient returns, perhaps 
in a few weeks, to be treated for some fresh 
"accident" or recurrence of original ones. 

Even if one is not inclined to accept the 
whole of Dubois' views concerning the psy- 
choneuroses and their treatment the results 
which he has obtained are momentous in that 
they exemplify the enormous possibilities 0/ 
psychic re-education associated with the more 
or less unconscious, but nevertheless positive, 
suggestive therapeutics which he denounces. 

With suitable cases one can institute a 
course of reading which includes books that 
tend to impress the patient with her true rela- 
tions with the outside world; ones which 
should decrease her ego-centricity, and which 
promote philosophical acceptance of the many 
inevitable disappointments which all must 
sustain. To this end one may recommend such 



Diagnosis, Prognosis and Treatment 423 

books as: "The Meditations" of Marcus 
Aurelius; the " Morals' ' of Seneca; the "Dis- 
courses" of Epictetus; Sir John Lubbock's 1 
■"Pleasures of Life;" Helen KeUer's "Optim- 
ism," and many others of like nature. 

In our efforts to dissipate individual symp- 
toms electricity is valuable. Not only is it, 
per se, a powerful suggestive agent, but it is a 
most efficient means of disguising suggestions 
which otherwise, being too obvious, would 
surely arouse the opposition that suggestion 
usually evokes when it is recognized as such. 
No one will deny that the various kinds of elec- 
tricity, particularly the impressive high fre- 
quency and static breeze treatments, are 
capable of acting in a powerful manner upon 
the mind of the patient. Except by reason of 
its psychic effect, however, it is difficult to un- 
derstand how electro-therapy can act benefi- 
cially upon a group of physical manifestations 
which are exclusively dependent upon path- 
ologic mental states. 

As with many other therapeutic agents the 
patient not uncommonly returns with the com- 
plaint that the first electrical treatment pro- 
duced decided aggravation of her symptoms, 
or even that it originated some new, and per- 
haps extraordinary, phenomena. In order to 
attempt to avoid this event the harmless 
nature of what she is about to undergo must 
be affirmed, and constantly during the course 



424 



Psychopathology of Hysteria 



of the treatment she must be reassured. Then, 
in case aggravation does occur, we can explain 
that it was merely due to the natural excite- 
ment attending the first treatment with such 
an awe inspiring agent, and that subsequent 
treatments will be followed only by salutary 
effects. Having dissipated her fears, or even 
without our attempts having been completely 
successful, it is absolutely necessary that the 
same treatment should be repeated; for no 
matter whether it was electricity or any other 
agent that was followed by aggravation, if the 
physician yields to the patient's remonstrances 
he loses all control and further efforts to benefit 
her may be unavailing. 

As patients generally expect to receive 
medicine some harmless remedy may be pre- 
scribed solely for its psychic effect except when 
some associated malady necessitates active 
treatment. Providing that there are no posi- 
tive indications for medicine the physician 
would do well to refrain from giving any to 
those who are disgusted with the unnecessary 
and fruitless drugging to which they have 
already been subjected — and there are many 
such. Beside usually being without justifica- 
tion, routine administration of bromides, 
strychnine and other active drugs may be de- 
cidedly harmful. Naturally bromides are in- 
dicated for the basic malady of a case in 
which symptoms of hysteria are superimposed 



Diagnosis, Prognosis and Treatment 425 

upon epilepsy, but in the absence of this par- 
ticular association of diseases bromides are 
worthless in the treatment of hysteria. Fur- 
thermore, bromides have a pernicious effect 
upon hysterics in that by reason of their seda- 
tive or stupefying effects they favor the produc- 
tion of dreamy or hypnoid states. 

Concerning the symptom insomnia, it is best 
not to allow the patient to gain the impression 
that she is taking any medicinal agent to favor 
the production of sleep. If some inert prepara- 
tion is given in order to satisfy her protests, 
and if the character of sleep improves by reason 
of the psychic effects of the supposed hypnotic, 
then the patient learns to depend upon outside 
assistance for the production of a state which 
should occur spontaneously. On the other hand, 
if the remedy really is a sedative a true drug 
habit is almost sure to be the outcome. To 
control insomnia let us avail ourselves of psy- 
chotherapy and of physical measures which in- 
duce actual fatigue. 

As all the symptoms of hysteria are mental 
in origin it must be conceded that whether we 
employ drugs, electricity, rest cures, work 
cures, or undisguised psychotherapy, which is 
in reality the sine qua non of success with any 
form of treatment, the disease can be treated 
successfully only with methods which act 
through the mind of the patient. In fact one 
may say that most of the methods of treatment 



426 Psychopathology of Hysteria 

of hysteria succeed only by reason of the skilful 
application of suggestion which they imply, 
and that with but few exceptions any system 
of therapeusis which is not based upon psycho- 
therapy — including psychic re-education — must 
be of little value when applied to the treatment 
of any of the psychoneuroses. 

Some physicians assert that notwithstanding 
the fact that they have never made use of sug- 
gestion still they have been quite successful in 
their treatment of hysteria. They fail to con- 
sider, however, the more or less unconscious 
suggestion which enters largely into the rela- 
tions between physician and patient, and their 
success may depend almost entirely upon the 
use of what to them is unconscious suggestion 
and rational psychic re-education. This fact is 
amply demonstrated by the failures of other 
physicians who employ the same drugs and 
other measures but whose personalities are such 
that they cannot command the patient's con- 
fidence, and they are unable to arouse a favor- 
able state of expectant attention. 

As suggestion is such an important factor in 
the production of the accidents of hysteria the 
logical mode of treatment is that in which this 
symptomatic exaggerated suggestibility is em- 
ployed for the removal of manifestations for 
which it is responsible. In hysteria dissociation 
of personality is accompanied by increased sug- 
gestibility which, in turn, is the cause of many 



Diagnosis, Prognosis and Treatment 427 

phenomena of the disease. Therapeutic use of 
suggestion tends to remove these manifesta- 
tions and to effect a cure by bringing about 
synthesis of the dissociated elements. 

In a bacterial disease the microbes elaborate 
a toxin which reacts upon the organism to pro- 
duce degeneration of the tissues and symptoms 
of toxaemia. Graduated application of auto- 
genous vaccines not only leads to disappearance 
of the symptoms but also to cure of the disease 
and immunization of the patient. In reply, 
therefore, to the contention that by means of 
an artificially induced hysteric state we pre- 
sume to cure hysteria one has only to refer to 
the successful application of the same mechan- 
ism in what is known as vaccine therapy. 

Besides psychic re-education and the analytic 
method of Freud the psychotherapeutic meth- 
ods employed for the removal of various 
symptoms consist in suppression, substitution, 
and revelation. 

With or without the induction of what is 
commonly known as the hypnotic state a symp- 
tom may often be suppressed by means of sug- 
gestion alone, but in itself this does not con- 
stitute cure of the disease. Briefly, the result 
is obtained merely by affirming that the mani- 
festation has disappeared, or will disappear 
shortly, and if the patient has sufficient con- 
fidence in the physician, or if the physician has 
sufficient command of the patient to enable him 



428 Psychopathology of Hysteria 

to override her passive resistance, the symptom 
vanishes. 

The method of substitution, originated by 
Janet, consists in reproduction during hypnosis 
of the pathogenic memory complex, and then 
substitution of a different series of associated 
ideas and a different outcome. For instance, 
when recurrences of crises are due to path- 
ologic association of ideas consequent upon a 
certain kind of stimulus, and each crisis is a 
repetition of the reaction to some former mental 
stress, then in place of the former complex 
the physician substitutes a pleasant series of 
ideas to be aroused by whatever acts as the 
hysterogenic stimulus. 

The method of revelation, a form of psychic 
re-education, depends upon demonstration to 
the patient of the psychic nature of the symp- 
toms in the hope that this will suffice to cause 
them to disappear. Thus, in case of monocular 
amaurosis the optical inconsistencies of the re- 
sults of tests can be adduced in order to con- 
vince the patient that she really sees with her 
blind eye. 

As the manifestations of hysteria are de- 
pendent upon dissociated or submerged com- 
plexes a patient really is not cured until we 
have effected synthesis with consciousness of 
what has been pathologically dissociated. This 
limitation becomes more obvious in connection 
with the most highly developed type of 



Diagnosis, Prognosis and Treatment 429 

hysteria — multiple personality. No matter how 
perfect the results of treatment of a case of 
dual personality may seem surely the person- 
ality which we have secured is not what might 
be termed normal unless the patient is capable 
of remembering what occurred during periods 
of the secondary state. Consequently, it is of 
the utmost importance that the cause of each 
manifestation be discovered, for no matter how 
bizarre they may seem each originated from 
some unpleasant experience whose nature 
must be ascertained before treatment can be 
instituted in an intelligent manner. 

The most logical and effective form of 
therapeusis includes the discovery, by means 
of some psycho-analytic method, of the causal 
submerged complexes; synthesis of these with 
consciousness; and, through the agency of 
psychic re-education, the removal of psycho- 
pathic tendencies. 



INDEX 



Absent mindedness, in- 
stance of normal, 99 

Achiria, 78 

Achromatopsia, 112 

Aerophagia, 154 

Age incidence of hysteria, 
34 

Ageusia, 133 

Alimentary disturbances, 
144 

Allochiria, 78 

Amaurosis, 89 
Etiology of, 90 
Character of, 96 
Systematized, 99 
Diagnosis of binocular 

amaurosis, 102 
Diagnosis of monocular 

amaurosis, 104 
Treatment, 110 

Amblyopia, 89 

Ambulatory automatism, 
292 

Amnesia, 252, 332 
Systematized, 341 

Amselle quoted, 114 

Anaesthesia, 56 
Etiology of, 56 
Character of, 65 
Interpretation of, 74 

Angell's case of subcon- 
scious fabrication, 376 

Angioneurotic oedema, 167 

Ankle clonus, 184 

Anorexia, 146, 315 

Anosmia, 133 

Anuria, 160 

Appetite, 156 

Aphasia, systematized, 341 

Appendicitis, pseudo, 157 

Argyll-Robertson pupil, 205 



Association of ideas, 150, 

240, 246, 248, 251, 255, 

270, 299 
Association reaction time 

experiments, 351 
Astasia-abasia, 192 
Asthma, 141 
Ataxia, static, 83 
Attention, 94, 361 

Distraction of, 96, 334 

Expectant, 140, 191, 208, 
246, 365 

Interference of, 94, 125, 
178, 363 
Aurae, 247 
Automatic writing, 58, 72, 

348 
Automatism, 16 

Ambulatory, 292 

Motor, 151 

B 

B, Madame, Case of, 324 
Bachman case, 379 
Bamberger's case of fever, 

171 
Beauchamp case, 100, 270, 

325, 349 
Bernheim quoted, 57, 62, 

262, 264 

Method of diagnosis of 
psycholepsy, 260 ♦ 

Method of treatment of 
psycholepsy, 264 
Binet ? s experiments with 

anaesthesia, 72 

Test for amblyopia, 103 
Blindness, see amaurosis 
Bordley on the color fields, 

123 
Bourne, Ansel, case, 304 
Briquet attacks, 224 



431 



432 Psychopathology of Hysteria 



Cannon, W. B., quoted, 145 
Cardiac neuroses, 165, 256 
Carpenter quoted, 150 
Catalepsy, 272 
Charcot 's experiments with 

dyschromatopsia, 113 

Conception of crises, 212 
Children, normal suggesti- 
bility of, 46, 368 
Chorea, rhythmical, 209 
Circulatory phenomena, 165 
Clonus, ankle, 184 
Colitis, entero, mucomem- 

branous, 158 
Color fields, inversion of, 

123 
Complemental opposition, 

186 
Concentric contraction of 

the visual fields, 114 
Contagion, psychic, 46, 216., 

225, 231 
Contractures, 199 
Convulsions, 212 

Epidemic, 53 
Core's case of eat 

272 

Courtney, J. W., quoted, 311 
Crises, 212 
Curschmann 's case of 

hyper hydrosis, 168 
Cushing on the color fields, 

123 



Darwin, quoted, 233 
Davenport, quoted, 53 
Deafness, 125 

Systematized, 132 
Deaf -mutism, 130 
Death from hysteria, 146 
Definition of hysteria, 29 
Delirium, 236, 349 
Delusions, 373 

Toxie, 43 



Dendritic retraction, theorv 
of, 384 

Dercum, C. T., quoted, 165 

Diagnosis, 394 

Digestion, Pawlow 's experi- 
ments on, 144, 245 

Diplopia, monocular, 206 

Dissociation of personality, 
19, 312 

Dreaming, day, 356, 407 

Dreams, spontaneous re- 
covery of submerged 
memories during, 18 
As a cause of symptoms, 

396 
Significance of, 390 

Dynamometric examina- 
tions, 178, 182 

Dyschiria, 78 

Dyschromatopsia, 111 

Dyspepsia, emotional, 145 



Ecstasy, 273 
Egocentricity, 359 
Elizabeth M., 226 
Emma F., 209 
Emotional crises, 219 

Dyspepsia, 145 

Instability, 355 

Keactions, 92, 194, 231, 
239, 387 

Eeaction, effects of sup- 
pression of, 239, 388 
Epidemic convulsions, 53 
Epidemic hysteria, 49, 231 
Epilepsy, pseudo focal, 218 

Hystero, 212 

Simulated by hysteria, 
218, 221 
Etiology, 31 

Heredity, 31 

Environment, 33 

Eaulty education, 33 

Age, 34 

Sex, 34 

Social factors, 36 



Index 



433 



Occupation, 37 

Eace, 38 

Climate, 38 

Acute psychic insults, 39 

Toxaemia, 42 

Psychic contagion, 46 

Spiritualism, 48 

Epidemic hysteria, 49 
Examinations interfered 

with by attention, 94, 

125, 178, 363 
Expectant attention, see 

attention 
Eye, disorders of the, 203 



Fabrication, subconscious, 

373 
Fales, Louis H., quoted, 39 
Falsification of memory, 

374 
Fasting, 146 
Fatigue, 419 
Fever, 170 
Flaubert, Gustave, case of, 

249 
Flees test of amaurosis, 108 
Florence K., ease of, 199 
Focachon ; s experiments, 

169 
Free will, 16 
Freud quoted, 264, 387 

Analytic method of, 344 

Theories of, 386 
Fugues, 292 

G 

Galton whistle, experi- 
ments with, 127 

Gangrene, 168 

Gastro-intestinal derange- 
ments, 136 

Gastric neuroses, 145 
Hair balls, 157 
Ulcer, simulation of, 152 

Genito-urinary derange- 
ments, 159 



Gowers, quoted, 47 
Gradle quoted, 96., 108 
Gustatory disturbances, 133 
Gynsecologic operations in 
hysterics, 164 



Habit formation, 13 
Habit spasms, 210 
Hsematemesis, 152 
Haemorrhage, spontaneous 

capillary, 166 
Hair balls of the stomach, 

157 
Hallucinations, 373 
Toxic, 43 

Systematized negative, 
99, 102 
Hallucinatory pain, 84 
Hammond quoted, 18, 286 
Hanna case of multiple 

personality, 318 
Hay fever, 138 
Healy quoted, 167 
Hearing, tests of, 126 
Hemianesthesia, 57, 62 
Hemianopsia, 124 
Hemiplegia, 181, 186 
Heredity, 31, 260 
Hiccough, 138 
Hoover's sign, 186 
Hyperesthesia, 84 
Hyperhydrosis, 169 
Hypnoidal state, 242, 345 
Hypnotism, normal sus- 
ceptibility to, 32 
Hypnotic suggestion, 98, 
102, 104, 110, 116, 168, 
191, 200, 210, 229, 237, 
239, 244, 253, 255, 278, 
292, 298, 307, 315, 323, 
326, 338, 344, 370, 372, 
373, 375 
" Hysterics ' ', 395 
Hystero-epilepsy, 212 
Hysterogenic zones, 244 



434 



Psychopathology of Hysteria 



lima S., experiments on, 
168, 170 

Incoordination, 82 

Insanity, 377 

Insomnia, 282 

Inversion of the color 
fields, 123 

Insular sclerosis, simula- 
tion of, 399 

Iridoplegia, reflex, 205 



Jacksonian epilepsy, pseudo, 

218 
Jacob, Sarah, case of, 148 
James, W., quoted, 21, 

248, 304 
Janet quoted, 64, 216, 279 
Jastrow quoted, 99, 391 
Jelliffe quoted, 382 
Jones, E., on dyschiria, 77 
Jones, E., quoted, 14, 223, 

336 



Kampmeier quoted, 163 
Keller, Helen, unconscious 

plagiarism of, 17 
Knapp's case of deafness, 

132 
Knee jerks, 183 
Knowledge, acquisition of, 

13 
Krafft-Ebing 7 s experiments 

with lima S., 168, 170 



M 
Mabel A., case of, 91, 130 
MacMurray quoted, 273 
Macnish's case of somno- 
lence, 276 
Macnish quoted, 276, 284 
Malingering, 74, 108, 148, 

152, 168, 357 
Marcelline, case of, 315 
Mary D., case of, 133 
Mayer, E. E., case of 
multiple personality, 312 
McArthur 's case of pleasur- 
able pain, 358 
Medicinal treatment, 265, 

424 
Memory, falsification of, 
374 

Loss of, see amnesia 
Memories, dormant, 12 
Normal dissociation of, 

14 
Dissociated, methods of 
recovery of, 342 
Menstrual disturbances, 

155, 164, 236 
Meteorism, 154 
Miss M., case of, 91 
Mitchell, J. K., case of 

mutism, 196 
Motor automatisms, 151 
Multiple sclerosis, simula- 
tion of, 399 
Murder, 379 
Mutism, 130, 193 
Mydriasis, 205 



Lady of Nismes, 276 
Lancereaux case of somno- 
lence, 275 
Lasegue's syndrome, 76 
Lateau, Louise, case of, 166 
Lizzie B., case of, 61, 120 



N 
Narcolepsy, 268 
Neuroses, cardiac, 165, 256 

Gastric, 145 
Nismes, Lady of, 276 
Nocturnal somnambulism, 

283 



Index 



435 





Ocular palsies, 203 
Oedema, angioneurotic, 167 
Oettinger's case of deaf 

mutism, 131 
Olfactory disturbances, 133 
Operations gynecologic, 164 
Operations for pseudo or- 
ganic disease, instances 
of, 156,, 157, 358 
Ophthalmoplegia, 203 
Opposition complemental, 

186 
Organic nervous diseases, 
differentiating features, 
183 
Ovarian pains, 164 



Pain, 84 

Ovarian, 164 

Pleasurable, McArthur 's 
case of, 358 
Paralyses, ocular, 203 
Paralysis, 173 

Etiology, 173 

Character of, 178 

Diagnosis, 181 

Systematized, 191 

Ocular, 203 
Paraplegia, 176, 180, 189, 

201 
Parinaud 's experiments 

with dyschromatopsia, 

111 
Parker, G. M., quoted, 221 
Patellar reflexes, 183 
Pawlow's experiments with 

digestion, 144, 245 
Perimetric examinations, 

115 
Personality, the normal, 11 

Dissociation of, 19 

Multiple, 312 



Perversion, sexual, 161 
Pitre's test of amaurosis, 

107 
Plagiarism unconscious, 16 
Polyopia, 206 
Polyuria, 159 
Possession, 51 
Prevision of crises, 246 
Prince's test of amaurosis, 

106 
Prince quoted, 67, 139, 

270, 348, 372 
Prognosis, 401 
Progressive muscular at- 
rophy, simulation of, 189 
Prophylaxis, 404 
Pseudocyesis, 155 
Psychasthenia, 252, 370, 

337 
Psychasthenic convulsions, 

212, 226,, 254, 262 

Anorexia, 149 

Fugue, 308 

Polyuria, 159 

Sexual perversion, 163 

Tics, 137, 210 
Psychic contagion, 46, 216, 

225, 231 
Psychic epilepsy, 221, 310 
Psycholepsy, 212 

' ' Grande hysterie f> , 213 

Classification of, 217 

Statistics, 218 

Emotional crises, 219 

lt Psychic epilepsy'', 221 

Mimicking epilepsy, 221 

Etiology, 225 

Aurae, 247 

Diagnosis, 257 

Prognosis, 261 

Treatment, 263 

Psychic contagion in, 246 
Psychomotor disorders, 173 
Pupillary phenomena, 205 



436 



Psychopathology of Hysteria 



B 

Eaeial incidence, 38 
Eaimiste's sign, 189 
Eeaction time experiments, 

351 
Eeflexes, 183 
Keflex iridoplegia, 205 
Eegnard 's experiments with 

dyschromatopsia, 113 
Eeligious hysteria, 49, 273, 

379 
Eespiratory derangements, 

136 
Eest cure, 418 
Eevivals, religious, 53, 231 
Eeynold's case of multiple 

personality, 320 
Ehinorrhcea, 138 
Ehythmical choreas, 209 
Eichardson, W. W., quoted, 

380 
Eomancing, 356, 407 

S 
Sallie S., case of, 239, 291 
Sclerosis, multiple, simula- 
tion of, 399 
Sexual incidence of hys- 
teria, 34 

Instinct, 161 

Origin of hysteria, 388 

Perversion, 161 

Eepression, effects of, 
389 
Sidis quoted, 45, 54, 162, 

222, 241, 319, 346, 371 
Simulation, 74, 108, 148, 

152, 168, 357 
Singultus, 138 
Sleep, theories of, 45 
Sleep walking and talking, 

283 
Smell, loss of the sense of, 

133 
Somnambulism, 282 

Nocturnal, 283 



Somnolence, 268 
Spasms, habit, 210 
Spastic paralysis, 188 
Speech disturbances, 193 
Spiritualism in the etiology 

of hysteria, 48 
Stigmata, 24, 84 
11 Stigmatics ' ', 166 
Stoeber 's test of amaurosis. 

107 
Suggestibility in hysteria, 

26, 58, 364 
Suggestion, 59 

Inversion of the color 
fields, 123 
Definition of, 371 

Suggestion, see also hyp- 
notism 

Suggestive examinations as 
a cause of symptoms, 24, 

27, 47, 59, 67, 79, 114 
Suicide, 378 
Sweating, 168 
Sympathy, desire for, 357 
Synchiria, 78 
Syndrome, Lasegue's, 76 



Talking, sleep, 283 

Taste, loss of sense of, 133 

Temperament, 354 

Theories, 382 

Tics, 137, 210 

Time, subconscious deter- 
mination of the passage 
of, 195, 294 

Toxaemia, 42 

Toxic hallucinations, 43 

Trance states, 268 

Traumatic hysteria, 36, 39, 
175, 196, 199 

Treatment, 409 

Tremors, 206 

Trophic. phenomena, 165 



Index 



437 



v 

Ulcer, gastric, simulation 

of, 152 
Unconscious plagiarism, 16 
Urinary retention, 161 

Suppression, 160 



Vasomotor phenomena, 166 

Visceral derangements, 136 

Vision, crystal, 348 

Visual fields, concentric 

ction 

Spiral, 119 

Bordley and dishing on 

the color fields, 123 



Visualization, 156 
Vive, Louis, case of, 322 
Volition, 363 
Vomiting, 149, 315 



W 

Walker, W. K., quoted, 12 
Walking, sleep, 283 
Walton 's case of fever, 271 
Wilson's case of malinger- 
ing, 358 
Woodman quoted, 378 



X., Mr., case of, 141, 293 



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